2024 Final Rule Part One: Split (or Shared) Evaluation and Management (“E/M”) Visits
According to the Centers for Medicare and Medicaid Services (“CMS”), Medicare Physician Fee Schedule Final Rule:
“Split (or shared) E/M visits refer to visits provided in part by physicians and in part by other NPPs in hospitals and other institutional settings. For CY 2024, we’re finalizing a revision to our definition of “substantive portion” of a split (or shared) visit to include the revisions to the CPT guidelines. For Medicare billing purposes, the “substantive portion” means more than half of the total time spent by the physician and or non-physician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making.”
Because of recent CPT guideline revisions, CMS will not allow documentation of history or exam as justification for split/shared billing, as these are no longer CPT concepts.
In 2024, CPT expanded the definition of split/shared services, stating the ‘substantive portion’ of a visit 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 now allow the substantive portion to be determined based on the practitioner who spent more than 50% of the time or who performed the medical decision making. CMS goes on to say, “we expect that whoever performs the MDM and subsequently bills the visit would appropriately document the MDM in the medical record to support billing the visit.” Services billed using the physician’s NPI are paid at a higher rate than those billed by a non-physician practitioner, and when billing Medicare for shared services, they may only be billed in a facility setting. Medicare also requires HCPCS modifier -FS to identify shared services.
The 2024 CPT book continues allowing practitioners to determine the substantive portion by time or MDM. If using time, the 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. CPT uses “other qualified health care professionals (‘QHP’)” while CMS uses “non-physician practitioners” to describe APRNs and PAs who bill E/M in their scope of practice. Services may include face-to-face and non-face-to-face activities. If using MDM to determine the substantive portion, CPT indicates, “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.”
Other requirements for a physician to bill a service as split/shared are:
- the physician and PA or NP must work for the same group
- the physician must provide their part of the service on the same day
- the physician must sign and date the medical record.
For documentation requirements specific to Medicare, PERCS recommends consulting with each MAC to get clear information regarding what is needed.
Keeping up with the rapidly changing rules of Split or (Shared) visits can be exhausting. PERCS is here to help you navigate guidelines to remain compliant. If you have any questions or need assistance, please contact Angie Spiros, COC, CPC, CPMA, Consultant at ASpiros@AskPHC.com or Lori Carlin, CPC, COC, CPCO, CCS, CRC, Principal, at LCarlin@AskPHC.com. They will be readily available to answer your questions and provide expert advice, so you are well equipped to move forward!
Be on the lookout for Article 2 of this series.
References:
p.6 CPT 2024 Professional Ed. AMA, 2024
https://public-inspection.federalregister.gov/2023-24184.pdf