Split/Shared 2022 and 2023 Changes

Definition

The CY2022 Final Rule defines a split/shared visit as “an E/M visit in a facility setting that is performed in part by a physician and an NPP who are in the same group.” It goes on to define facility setting as “institutional setting” in which institutions are limited to hospitals and the new addition of skilled nursing facilities or “SNFs.” This, of course, still does not apply to an office setting in which incident-to guidelines need to be followed.

Billing Provider and Documentation Guidelines

2022 is a transitional year with 2023 being the year with the Final Rule fully enacted. In 2022, the Final Rule requires the split/shared encounter to be billed under the provider who performs the substantive portion of the encounter. A substantive portion is defined as more than 50% of the total time of the patient encounter, or the practitioner who performed and documented in its entirety either the history, exam, or medical decision-making. Documentation in the medical record must identify the physician and NPP who performed the visit. The individual who performed the substantive portion of the visit (and therefore bills for the visit) must sign and date the medical record.

In 2023, the Final Rule defines substantive portion as more than half the total time spent by the practitioner whether it be the physician or the NPP, therefore each practitioner must document their visit time within the note.

For all split/shared visits, one of the practitioners must have face-to-face (in-person) contact with the patient, but it does not necessarily have to be the physician, nor the practitioner who performs the substantive portion and bills for the visit. The substantive portion can be entirely with or without direct patient contact, and is determined by the proportion of total time, not whether the time involves patient contact.

According to CPT E/M Guidelines, only distinct time can be counted. When the practitioners jointly meet with or discuss the patient, only the time of one of the practitioners can be counted.

Previously, split/shared only applied to established, subsequent visits, critical care, and prolonged services. Now, split/shared also applies to initial visits.

To make the definitive difference when submitting split/shared claims, the Final Rule has added a modifier. Modifier FS must be appended to the claim to permit identification and tracking of these encounters. This includes critical care.

      *Office visits are not billable as split/shared services.

Prolonged Services

Beginning January 1, 2023, the physician or practitioner who spends more than half the total time (the substantive portion) will bill for the primary E/M visit and the prolonged service codes when the service is furnished as a split/shared visit. This is providing that all other requirements to bill for split/shared services are met.

For CY2022 shared hospital outpatient visits, where practitioners use a key component as the substantive portion, prolonged services can be reported by the practitioner who reports the primary service when the combined time of both practitioners meets the threshold for reporting prolonged hospital outpatient services (HCPCS code G2212).

For all other types of E/M visits (except emergency department and critical care visits), prolonged services can be reported by the practitioner who reports the primary service, when the combined time of both practitioners meets the threshold for reporting prolonged E/M services other than office/outpatient E/M visits (60 or more minutes beyond the typical time in the CPT code descriptor of the primary service).

Reporting Prolonged Services for Split/Shared Visits

*Office visits are not billable as split/shared services.

Critical Care

For CY2022 critical care services, since those codes are based on time alone, the billing provider is the provider who dedicated more than half of the total time spent. Again, signatures, and clear documentation of the time spent for each practitioner needs to be documented. CY2023 has the same documentation guidelines for critical care services.

In the context of critical care, split/shared visits occur when the total critical care service time provided by a physician and NPP in the same group on a given calendar date to a patient is totaled and the practitioner who provided the substantive portion of the cumulative critical care time reports the critical care service.

Beginning January 1, 2023, substantive portion means more than half of the total time spent by the physician and NPP performing the split/shared visit.

Modifier FS must be appended to critical care codes for split/shared claims.

When the critical care service is unrelated to a procedure, append modifier FT: unrelated evaluation and management (E/M) visit during a postoperative period, or on the same day as a procedure or another E/M visit.

Impact

Physicians should be aware of the potential revenue impact and workflow changes that may occur. Split/shared visits no longer guarantee the higher physician level reimbursement but will be dependent on who is providing the most substantive portion of the visit. By 2023, all split/shared notes must include a documented element of time spent by each practitioner.

Sources:

https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2022-medicare-physician-fee-schedule-final-rule

https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-415

https://www.cms.gov/files/document/r11181bp.pdf