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Last Modified: 2/18/2024 Location: FL, PR, USVI Business: Part A, Part B

Split or shared E/M guidelines: Medicare Claims Processing Manual updates

Medicare evaluation and management (E/M) guidelines are now in effect regarding split or shared services. The CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, section 30.6.18 external pdf file includes a detailed breakdown of the split or shared guidelines. We’ve also summarized these changes below.

Definition of split or shared visit

A split or shared visit is an E/M visit in the facility setting that is performed in part by both a physician and a nonphysician practitioner (NPP) who are in the same group, in accordance with applicable law and regulations such that the service could be billed by either the physician or NPP if furnished independently by only one of them. Payment is made to the practitioner who performs the substantive portion of the visit.
Facility setting means an institutional setting in which payment for services and supplies furnished incident to a physician or practitioner’s professional services is prohibited under Medicare regulations.

Definition of substantive portion

Beginning January 1, 2024, substantive portion means more than half of the total time spent by the physician and or nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making.
During the transitional period, from January 1-December 31, 2023, except for critical care visits, the substantive portion can be one of the three key E/M visit components (a medically appropriate history or exam, or medical decision-making [MDM]), or more than half of the total time spent by the physician and NPP performing the split or shared visit. In other words, for calendar year 2023, the practitioner who spends more than half of the total time or performs the medically appropriate history or exam described in the code descriptor or MDM can be considered to have performed the substantive portion and can bill for the split or shared E/M visit.
When one of the three key components is used as the substantive portion in 2023, the practitioner who bills the visit must perform that component in its entirety.
For critical care visits, starting for services furnished in CY 2022, the substantive portion will be more than half of the total time.

Distinct time

When the practitioners jointly meet with or discuss the patient, only the time of one of the practitioners will count.

Qualifying time

Drawing on the CPT E/M guidelines, except for critical care visits, the following listing of activities will count toward total time for purposes of determining the substantive portion, when performed and whether the activities involve direct patient contact:
Preparing to see the patient (for example, review of tests)
Obtaining and/or reviewing separately obtained history
Performing a medically appropriate examination and/or evaluation
Counseling and educating the patient/family/caregiver
Ordering medications, tests, or procedures
Referring and communicating with other health care professionals (when not separately reported)
Documenting clinical information in the electronic or other health record
Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
Care coordination (not separately reported)
Practitioners cannot count time spent on the following:
The performance of other services reported separately
Travel
Teaching that is general and not limited to discussion required for the management of a specific patient
For all split or shared visits, one of the practitioners must have a 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.

Application to prolonged services

For 2022 and 2023 transitional years, the billing practitioner reports the codes for the primary service and the prolonged services, regardless of the amount of time the billing practitioner spent.
Starting in 2024, since the substantive portion is more than half of the practitioners’ total time, the physician or practitioner who spent more than half the total time (the substantive portion starting in 2024) will bill for the primary E/M visit and the prolonged service code(s) when the service is furnished as a split or shared visit, if all other requirements to bill for split or shared services are met. Upon meeting the threshold for reporting prolonged services, the physician and NPP will add their time together, and whoever furnished more than half of the total time, including prolonged time, (that is, the substantive portion) will report both the primary service code and the prolonged services add-on code(s).
During the transitional calendar years 2022-2023, when practitioners use a key component as the substantive portion, emergency department and critical care visits are not reported as prolonged services.

New and established patients, and initial and subsequent visits

You may bill split or shared visits for new and established patients, as well as initial and subsequent visits, that otherwise meet the requirements for split or shared visit payment.

Settings of care

Split or shared visits are furnished only in the facility setting, meaning institutional settings in which payment for services and supplies furnished incident to a physician or practitioner’s professional services is prohibited under our regulations at 42 CFR 410.26
Accordingly, split or shared visits are billable for E/M visits furnished in hospital and skilled nursing facility (SNF) settings. Visits in these settings that are required by our regulations to be performed in their entirety by a physician are not billable as split or shared services. For example, our Conditions of Participation require certain SNF visits to be performed directly and solely by a physician; accordingly, those SNF visits cannot be billed as a split or shared visit.

Medical record documentation

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.

Split or shared critical care visits

Critical care visits may be furnished as split or shared visits. Specifically, the billing practitioner bills the initial service (CPT 99291) and any add-on codes(s) for additional time (CPT 99292). In the context of critical care, split or shared visits occur when the total critical care service time furnished by a physician and NPP in the same group on a given calendar date to a patient is summed, and the practitioner who furnishes the substantive portion of the cumulative critical care time reports the critical care service(s).
Append modifier -FS (split or shared E/M visit) to the critical care CPT code(s) on the claim.
The same documentation rules apply for split or shared critical care visits as for other types of split or shared E/M visits. Consistent with all split or shared visits, when two or more practitioners spend time jointly meeting with or discussing the patient as part of a critical care service, count the time only once for purposes of reporting the split or shared critical care visit.

Critical care and other same-day E/M visits

Physicians in the same group who are in the same specialty must bill and be paid for services under the Physician Fee Schedule as though they were a single physician. If more than one E/M visit is provided on the same date to the same patient by the same physician, or by more than one physician in the same specialty in the same group, only one E/M service may be reported, unless the E/M services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. This general policy is intended to ensure that multiple E/M visits for a patient on a single day are medically necessary and not duplicative.
However, in situations where a patient receives another E/M visit on the same calendar date as critical care services, both may be billed (regardless of practitioner specialty or group affiliation) as long as the medical record documentation supports: 1) that the other E/M visit was provided prior to the critical care services at a time when the patient did not require critical care, 2) that the services were medically necessary, and 3) that the services were separate and distinct, with no duplicative elements from the critical care services provided later in the day. Practitioners must use modifier -25 (same-day significant, separately identifiable E/M service) on the claim.

Critical care visits and global surgery

Critical care visits may be needed during the global surgery period of a procedure, whether pre-operatively, on the same day, or during the post-operative period. In those cases where a critical care visit is unrelated to the procedure with a global surgical period, critical care visits may be paid separately in addition to the procedure. When the critical care service is unrelated to the procedure, append the modifier -FT (unrelated E/M visit on the same day as another E/M visit or during a global procedure [preoperative, postoperative period]), or on the same day as the procedure.

Claim Identification


Report modifiers on claims for split or shared visits, to identify the service met criteria for processing and potential separate payment. The table below lists these modifiers.

Modifier
Definition
Use with
Append to
Modifier -FS
Split or shared E/M visit
Split or shared services
E/M code
Modifier -FT
Unrelated E/M visit on the same day as another E/M visit or during a global procedure (preoperative, postoperative period, or same day as procedure)
Critical care unrelated to surgical procedure during global period
Critical care code
Modifier -25
Significant, separately identifiable E/M service on same day
Non-critical care E/M for significant, separately identifiable E/M service on same day as a procedure for which separate payment may be made
E/M code
Note: The modifier identified by CPT for purposes of reporting partial services (modifier -52 [reduced services]) cannot be used to report partial E/M visits, including any partial services furnished as split or shared visits. Medicare does not pay for partial E/M visits.

Example

If the NPP first spent 10 minutes with the patient and the physician then spent another 15 minutes, their individual time spent would be summed to equal a total of 25 minutes. The physician would bill for this visit since they spent more than half of the total time (15 of 25 total minutes). If, in the same situation, the physician and NPP met together for five additional minutes (beyond the 25 minutes) to discuss the patient’s treatment plan, that overlapping time could only be counted once for purposes of establishing total time and who provided the substantive portion of the visit. The total time would be 30 minutes, and the physician would bill for the visit since they spent more than half of the total time (20 of 30 total minutes).
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