Medicare has specific rules for billing for nurse practitioners and physician assistants using shared services.  These rules are explained in this article.

CodingIntel members can also download the Medicare Incident-to and Shared Services Coding Guide and split/shared quick reference sheet

Definition

Shared or split services are Evaluation and Management (E/M) services performed jointly between a physician and a non-physician practitioner (NPP), in the same group/same specialty, in a facility setting.

Explanation

Services may include both face-to-face and non-face-to-face activities, as defined by CPT®. Services billed using the physician’s NPI are paid at a higher rate than those billed by a non-physician practitioner (85% of the physician fee schedule rate) by Medicare. Shared services may be done in the inpatient setting, observation, outpatient department, ED and nursing facility.

Codes

Evaluation and Management services performed in a facility setting. Split/shared services may not be done in an office setting, place of service 11. They may be done in outpatient departments or provider-based clinics.

Overview of coding for shared services

CPT® added the concept of split/shared services in 2021, but their coding explanation did not describe reimbursement. This page describes Medicare reimbursement policy. Practices need to look at each commercial payer’s website for their policies.

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Billing and Coding Rules for Shared Services

CMS is requiring that the shared visit be reported under the provider number of the physician or non-physician practitioner who has performed the substantive portion of the visit. If the physician is not performing the substantive portion of the service, then report the service under the NPP provider number.

2024 Update: CMS is proposing for 2024 to continue to allow two options in determining who performed the substantive portion. This continues their 2022 & 2023 policy. The practitioner who performed more than 50% of the time of the visit (face-to-face and non-face-to-face) or the practitioner who performed and documented in its entirety either the history, exam, or medical decision-making portion of the note has done the substantive portion.

“We are clarifying that when one of the three key components is used as the substantive portion in 2022, the practitioner who bills the visit must perform that component in its entirety in order to bill. For example, if history is used as the substantive portion and both practitioners take part of the history, the billing practitioner must perform the level of history required to select the visit level billed.”

CMS 2022 Final Rule, page 430.

• May continue to use this in 2023

Office visits in an outpatient department can use either time or MDM to determine the substantive portion. If the physician performs and documents all of the assessment and plan, then consider that the substantive portion. If the physician spends more than 50% of the time, consider that the substantive portion. If neither of those is true, bill under the NPP provider number.

For emergency department visits, you must select the level of service based on medical decision making. But you can determine the substantive portion either by the practitioner who spent to the most time, or the key components. If the physician documents in its entirety either the history, exam or MDM, bill under the physician’s NPI.  And, bill under the physician’s NPI if the physician spends more than 50% of the time of the service.

For inpatient, observation and nursing facility services, if billing under the physician’s NPI, use either time or one of the key components to support the substantive portion. Either the physician must have spent greater than 50% of the time, and time must be documented, or the physician must have documented one of the key components in its entirety. If using time, both clinicians will need to document their time, so that it is clear which practitioner spent more than 50%. Use the current activities listed in CPT. Visits in a nursing facility which are mandated to be performed by a physician may not be billed as split/shared visits.

If billing shared services, the documentation must identify the two individuals who performed the service. CMS points out that in prior years, they finalized a rule that

“any individual who is authorized under Medicare law to furnish and bill for their professional services, whether or not they are acting in a teaching role, may review and verify (sign and date) the medical record for the services they bill, rather than re-document notes in the medical record…”

2022 Final Rule, page 445

They say it may be helpful for each individual to document their own participation in the record, in order to determine the substantive time. They state that the record must identify the two individuals who performed the services, and

“The individual who performed the substantive portion (and therefore, bills the visit) must sign and date the medical record.”

2022 Final Rule, page 446

Key Issues

• Append HCPCS modifier FS- Split (or shared) Evaluation and Management service on all shared services, whether reported by the physician or NPP
• If using time, both clinicians must document the time spent in the record
• If using MDM, one of the key components must be documented in its entirety by the clinician who is reporting the services. This is confounding because the E/M services are no longer defined by key components. My suggestion: use MDM.
• Identify both clinicians who participated in the care