In 2024, CPT expanded its definition of split/shared services, CMS updated their requirements.
- CPT expanded its definition of split/shared services in 2024, stating that the substantive portion can be determined by the practitioner who spent more than 50% of the time, or who made or approved the medical decision making.
- CMS will allow the substantive portion to be determined based on the practitioner who spent more than 50% of the time or the practitioner who performs the medical decision making (MDM). They have removed allowing documenting history or exam in its entirety, since these are not current CPT concepts.
- CMS continues to say that this is a delay until 2025 when only time can be used, but this is the third delay by my count.
- CMS says when the work is shared, “we expect that whoever performs the MDM and subsequently bills the visit would appropriately document the MDM in the medical record to support billing of the visit.”
- Services may include both face-to-face and non-face-to-face activities.
- Services billed using the physician’s NPI are paid at a higher rate than those billed by a non-physician practitioner.
- For Medicare, shared services may only be done in a facility setting; shared services may not be performed in place of service 11 for Medicare patients. CMS notes that there is an incident to benefit for the non-facility setting.
- CPT is silent about location.
- Medicare requires HCPCS modifier FS- Split (or shared) Evaluation and Management service to identify shared services.
- Terminology: CPT uses “other qualified health care professionals” and CMS uses “non-physician practitioners” to describe APRNs and PAs who have E/M in their scope of practice in the E/M section of the CPT book.
CPT Split/Shared Services Guidance 2024
All CPT quotes from p.6 CPT 2024 Professional Ed. AMA, 2024
E/M services may be billed as shared or split services when they are jointly performed by a physician and another practitioner who has E/M in their scope of practice, i.e., APRNs, PAs. CPT notes that physicians and qualified health care professionals (QHPs) often act as teams in caring for patients, and may work together during a single encounter. The 2024 CPT book continues to allow practitioners to determine the substantive portion by time or MDM. If using time, he practitioner who spent greater than 50% of the time can report the service; time spent with the patient jointly by both practitioners can only be counted once.
If using MDM to determine the substantive portion. CPT says:
“… performance of a substantive part of the MDM requires that the physician(s) or other QHP(s) made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management. By doing so, a physician or other QHP has performed two of the three elements used in the selection of the code level based on MDM.”
But, CPT adds a distinction between the three elements. If the number and complexity of problems and risk are used to select the level of service, the encounter can be reported by the practitioner who “takes responsibility for that plan.” If data is one of the three elements it is more complicated.
“If the amount and/or complexity of data to be reviewed and analyzed is used by the physician or other QHP to determine the reported code level, assessing an independent historian’s narrative and the ordering or review of tests or documents do not have to be personally performed by the physician or other QHP, because the relevant items would be considered in formulating the management plan. Independent interpretation of tests and discussion of management plan or test interpretation must be personally performed by the physician or other QHP if these are used to determine the reported code level by the physician or other QHP.”
That is, if data is one of the elements in selecting the level of service and there is an independent interpretation or discussion of management or test results with another health care professional that is being used to select the level of code, those activities must be done by the billing clinician (to support the substantive portion). Side note: This will be difficult to explain to practitioners and audit.
Location and wording
CPT is silent about location, not restricting the use of split/shared services to any location.
CPT is silent about who must document the visit. The wording, “…made or approved the management plan…” seems to imply that an attestation statement is sufficient.
CMS rules 2024
Location and wording
CMS continues to use the terms “nonfacility” and “noninstutional” to describe place of service where split/shared services are allowed. Specifically in the 2024 Final Rule, they state that in the office, incident to rules apply, not split/shared. Use CPT place of service codes to determine if the setting is a facility or non-facility. Office and other outpatient services (99202–99215) reported in place of service 11 office may not be reported as shared services. Office and other outpatient codes in place of service 19 or 22, outpatient hospital, may be reported as shared services.
This is what CMS says about documentation of split/shared services. “Although we continue to believe there can be instances where MDM is not easily attributed to a single physician or NPP when the work is shared, we expect that whoever performs the MDM and subsequently bills the visit would appropriately document the MDM in the medical record to support billing of the visit.” p. 475 of the Final Rule. Link at the end of the article.
“Appropriately document” is not defined by CMS. However, some MACs in 2023 have described what the physician needs to document to support billing the substantive portion. NGS, in their E/M Q&A section says this:
“10) Would you consider a shared/split service if the MD’s documentation was listed as an addendum on the NPP’s note?
Answer: Split/shared services in the hospital setting require performance of the medically necessary elements (history, exam, MDM) or cumulative time spent by both the billing physician and NPP. The only way for a physician and NPP to describe his/her own personal contribution to the service is to document an individual note describing the portion of the service performed.
Example: “I have seen and examined the pt. with the PA and agreed with A/P and physical exam findings (and then a summary of items/data already listed by the PA,” the physician is indicating his/her participation in the physical examination and review of the medical decision making; this would be adequate to support the physician’s participation.
In order to bill the service as the “substantive” provider, the physician’s documentation would need to describe the physician’s work as exceeding the NPP’s work in completing the service. In either reviewing the NPP’s history and/or exam findings and in formulating a medical decision, the physician’s performance and documentation would need to exceed the NPP’s efforts and documentation of the split/shared service.”
If NGS is your MAC, the physician must document their own medical decision making, if MDM is used to select the code level. Check your own MAC.
CMS Final Rule can be found here:
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