[author: Elin Baklid-Kunz*]

Compliance Today (May 2024)

Split (or shared) visits—the current term used by the Center for Medicare & Medicaid Services (CMS)—allow non-physician practitioners (NPPs) and physicians who work for the same employer/entity to share patient visits on the same day by billing the combined work under the physician’s National Provider Identifier (NPI) and receive 100% of the Medicare Physician Fee Schedule (MPFS), or the NPP’s NPI for reimbursement of 85% of the MPFS.

In the 2024 MPFS Final Rule, CMS revised the definition of “substantive portion” of a split (or shared ) visit to reflect the revisions made by the American Medical Association’s (AMA) Current Procedural Terminology (CPT) Editorial Panel.^[1] CMS removed history and exam from the definition of substantive portion and adopted the determination of medical decision making (MDM) as defined by CPT as the provider who “made or approved the management plan.”

There are two ways for providers to meet the guidelines, and the billing provider is determined by the provider who performs:

1. more than half of the total time, or

2. a substantive part of the MDM as defined by CPT (except for critical care visits, which use time only and are not MDM).

The revised policy is somewhat unexpected, as CMS has several times delayed a proposed policy that “whichever of the providers who spends the most time” would bill the service.

While there are many articles for providers on how to be compliant going forward, for auditors and providers facing retrospective audits, things are a little bit more confusing—specifically for auditors working in the legal space who frequently perform audits based on the different guidelines in effect for the different dates of service. For example, an auditor may be asked to review evaluation and management (E/M) services where the scope also includes compliance with split (or shared) services from 2021 to 2024. This would be a challenge with the different guidelines for split (or)shared services with different rules based on 2021 and prior, 2022 to 2023 new policy and transition, and 2024 revisions. To complicate this further, AMA had major revisions to the CPT Documentation Guidelines for outpatient office visits (CPT 99202–99215) in 2021 and for the remainder of E/M services in 2023 that impacts how E/M services are documented and reviewed.

Background Medicare’s split (or shared) visits—2021 and prior

Prior to 2002, the role of NPPs and the appropriate billing practices related to the services they provided in the facility setting were not clearly defined. Typically, NPPs such as nurse practitioners and physician assistants—also referred to as qualified healthcare practitioners (QHP) by the AMA—would assist physicians in the hospital with rounding or seeing patients in the emergency room, and these services were billed under the physicians’ NPIs. While certain documentation requirements applied, they were not clearly defined and varied by payer.

In October 2002, CMS Transmittal 1776 introduced Medicare’s payment policy for split (or shared) E/M visits.^[2] However, the full definition was introduced in Transmittal 808 in January 2006; it updated CMS Internet Only Manual: Medicare Claims Processing Manual (MCPM) Publication 100-04, Chapter 12, Section 30.6.1.H Split/Shared E/M Visit. (This section has since been removed):^[3]

A split/shared E/M visit cannot be reported in the SNF [skilled nursing facility]/NF [nursing facility] setting. A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer. The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and non facility clinic visits, and prolonged visits associated with these E/M visit codes). The split/shared E/M policy does not apply to consultation services, critical care services or procedures.

This allowed physicians to be reimbursed at 100% of the MPFS, although the NPP may have done most of the work if the physician performed and documented a face-to-face portion on the same calendar day.

These regulations remained in effect until CMS removed the MCPM sections related to split (or shared) E/M visits on May 26, 2021,^[4] preparing for the revised payment rules, which were published in the 2022 MPFS Final Rule in November 2021.^[5] It should also be noted that with the removal of the guidelines and until CMS published the final rule, CMS stated that “the agency will limit review.”

Revised policy and CMS transition period 2022–2023

Both 2022 and 2023 are considered transition years before CMS revised the policy for 2024; however, the major changes were effective in 2022.

With the revised policy—effective on January 1, 2022—split (or shared) E/M visits can only be performed in the facility setting (i.e., hospital inpatient/outpatient and emergency room); they can no longer be performed in an office setting, such as place of service 11. Prior to 2022, split (or shared) services were allowed in the office setting if incident-to were also met.^[6] CMS added SNF E/M visits to services that can be split (or shared) except for SNF E/M visits that are required to be performed in their entirety by a physician; however, NF visits remained not billable as split (or shared) services.

Also new for 2022 was the addition of critical care services to E/M services that may be performed as split (or shared) and a new modifier -FS, which is required on Medicare claims to indicate the services were split (or shared) E/M visits.

For 2022, there were two ways for providers to meet the guidelines for billing split (or shared)—determined by the provider who performed the “substantive portion” of the visit—which was further defined as the provider who:

1. Performed more than half of the total time of the visit, or

2. Fully performed one of the three key components, history exam, or MDM.

The exception was critical care services, which must meet the “greater than 50%” definition of substantive portion. Perhaps the biggest change for 2022 was that time can now include non-face-to-face time.

The 2022 MPFS Final Rule also contained a separate definition for the “substantive portion” for 2023: whichever providers spend the most time would bill the service. However, the implementation of billing only based on time spent was delayed until at least December 31, 2024.

This new payment policy and the substantive portion are codified in 42 C.F.R. § 415.140:^[7]

Split (or shared) visit means an evaluation and management (E/M) visit in the facility setting that is performed in part by both a physician and a nonphysician practitioner 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 nonphysician practitioner if furnished independently by only one of them.

Substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making except as otherwise provided in this paragraph. For critical care visits, substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit.

Prior to 2022, AMA updated their office/outpatient E/M visits guidelines for 2021, allowing providers to select the level of office visits based on the amount of time spent with the patient or the level of MDM.^[8] For coding purposes, history and physical exam documentation were eliminated, and total time was updated to include non-face-to-face time personally spent by the provider or NPP, but not other clinical staff. Non-face-to-face time includes activities such as preparing to see the patient, ordering procedures, etc.

It should also be noted that the AMA introduced a split (or shared) visit definition in the CPT manual for the first time in 2021. Although CMS did not adopt the CPT definition, the CPT time guidelines can be used. CPT defines the specific activities, which can be found in the E/M guidelines section of the CPT book.

Documentation

Documentation for split (or shared) visits should follow the guidelines for any E/M service and must support the combined service level reported on the claim. Both providers should personally document their portion of the visit separately in the medical record, as documentation should clearly indicate the services provided by each individual. If time is used for the level, the documentation should include time spent by each provider.

Prior to the 2022 changes, the documentation requirements for split (or shared) visits were focused on ensuring the physician performed and documented a face-to-face encounter with the patient on the same day as the NPP.

The policy then requires the provider who bills the service to perform a “substantive” component, starting with 2022. The new definition of substantive means the provider must document one of the components in its entirety, such as history, exam or MDM, or bill based on time.

Then, for 2024, since history or exam are no longer relevant for coding purposes, the billing provider must document the MDM in its entirety or bill based on time.

Medicare’s conditions of payment require that the documentation in the medical record identify the physician and NPP who performed the visit, and that the billing provider who is performing the substantive portion must sign and date the medical record.^[9] For billing purposes, starting with 2022, the designated modifier -FS must be included on the claim to identify that the services are split (or shared).

As for any medical record documentation, it is important to avoid copy-and-paste errors, by ensuring that documentation is unique to each patient encounter and avoiding copying and pasting information from previous encounters. Each encounter should reflect the specific details of that visit. Providers should exercise caution with canned statements.

For example, it is not uncommon to see attestation statements when reviewing split (or shared) services, and often these statements are not sufficient. For example: “I, the attending emergency medicine physician, provided a substantive portion of the care of this patient. I personally performed the medical decision making in its entirety, in addition to components of the history and physical exam, for this encounter.”

This statement alone would not likely pass a payer audit if the medical record also does not contain documentation of what the physician actually performed.

Billing based on time

Before 2023, in the facility setting (2021 for office visits), providers could use time as the determining factor for E/M services by documenting total time, the content of the counseling or coordination of care, and documentation that more than half of the time was spent on counseling or coordination of care. (i.e., “20 minutes of the 30-minute visit spent counseling the patient on . . .”). This is often referred to as using “time based counseling or coordination of care” and was eliminated in 2023 when CPT expanded the 2021 documentation guidelines where visits are based on total time or MDM, to apply to all EM visit codes (except critical care services).^[10]

The biggest change with time, however, is allowing “non-face-to-face” time spent on the same date to be used for split (or shared) visits as long as one of the practitioners has face-to-face (in-person) contact with the patient. It does not necessarily have to be the physician or the NPP 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.

Examples of non-face-to-face time include time preparing to see the patient, reviewing test results, or discussing the patient’s care with other providers. For example, activities that cannot be counted include traveling and teaching.

It is essential that each provider documents their distinct time in the medical record. And when two or more providers jointly meet with or discuss the patient, only the time of one individual should be counted. For example:

If the NPP sees a hospital patient in the morning and spends 10 minutes, and the physician follows up later the same calendar day with a 15-minute visit, the physician may report the service based on time. The total time for the visit would be 25 minutes, and the provider who spent more than 50% of the visit—the physician—can report the service.

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).

This captures the main intent behind the split (or shared) service, as it allows the NPP to see patients while the physician may be in surgery or otherwise unavailable. The physician would then see the patient later in the day, such as more complex patients who need the physician’s experience. The split (or shared) rules were not designed to encourage physicians to simply stop by to see the patient to capture the additional 15% in revenue or only sign off on the medical records after the NPP visit. However, it should be noted that CMS— in the 2024 Final Rule—specifically stated: “We note that the policy is not about whether the physician’s expertise is ‘necessary’ for the visit but rather whether the physician or the NPP should bill for the service when each of them are performing part of an E/M visit.”^[11]

Compliance with split (or shared) E/M visits

Many of the recent overpayments, audits, Civil False Claims Act, and even criminal cases instituted by the federal and state agencies overseeing the Medicare and Medicaid programs involve allegations of improper billing for “incident-to” services and split (or shared) services.

One example is the recent False Claims Act case against TeamHealth, who settled for $48 million in 2021. The realtors alleged that TeamHealth engaged in a scheme to defraud Medicare by overbilling for services provided by NPPs by submitting claims for reimbursement for services performed by NPPs but using physicians’ NPIs, which inflated their reimbursement rate. The relators alleged that TeamHealth covered up this practice by characterizing NPP services as split (or shared) E/M services.^[12]

To prepare for potential increased audit scrutiny, if your practice employs NPPs, any E/M audit should include services performed split (or shared) as well as services performed incident-to.

Practices should consider the following steps for compliance:

1. Understand current policy: Familiarize yourself with Medicare and CPT guidelines for split (or shared) E/M visits. See Figure 1.

2. Payer difference: Query payers to understand their policy for split (or shared) visits.

3. Perform baseline audit: Assess your compliance by performing a baseline audit.

4. Educate providers: If discrepancies or issues are identified, provide feedback to the involved providers and educate them on Medicare and other payers’ specific guidelines.

5. Implement corrective actions: If necessary, implement corrective actions to address any identified issues. This may include additional training for providers or improvements to documentation processes. It may include changes to workflows and roles affected by the revisions for 2024.

6. Monitor compliance: Establish an ongoing monitoring process to ensure ongoing compliance with Medicare guidelines for split (or shared) E/M visits. Regularly audit sample documentation to identify and address any issues promptly. A checklist can be used to help with this.

7. Stay informed: Keep abreast of any updates or changes to Medicare guidelines. Medicare policies can change, and staying informed will help ensure ongoing compliance. And make sure to monitor updates from your Medicare administrative contractors, as we can expect additional information based on the revised policy.

Last, remember that the new modifier -FS will make it easier for Medicare to monitor claims and ensure that providers are correctly billing for split (or shared) E/M services.

Takeaways

• Understand the different timelines and guidelines for auditing split (or shared) visits: 2021 and prior, 2022–2023 new and transition and 2024 revisions.

• Use an auditor reference tool to help with retrospective audits.

• The Centers for Medicare & Medicaid Services only allow split (or shared) visits in the facility setting (i.e., hospital, emergency room) starting with calendar year 2022; however, Current Procedural Terminology is silent on location and may be allowed in the office setting.

• Time for split/shared service may include both face-to-face and non-face-to-face activities.

• Perform a baseline audit to ensure compliance with Medicare’s updated split (or shared) visit policy.

*Elin Baklid-Kunz is a Healthcare Consultant at KUNZ LLC in Orlando, Fl.

1 Centers for Medicare & Medicaid Services, CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program, 88 Fed. Reg. 78,818 (Nov. 16, 2023), https://www.federalregister.gov/documents/2023/11/16/2023-24184/medicare-and-medicaid-programs-cy-2024-payment-policies-under-the-physician-fee-schedule-and-other.

2 Centers for Medicare & Medicaid Services, “New/Revised Material – Effective Date: July 1, 2001, Implementation Date: October 25, 2002,” Transmittal 1776, Change Request 2321, October 25, 2002, https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1776B3.pdf.

3 Centers for Medicare & Medicaid Services, “Nursing Facility Service (Codes 99304 – 99318),” CMS Manual System, Pub 100–04 Claims Processing, Transmittal 808, Change Request 4246, January 6, 2006, https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R808CP.pdf.

4 Centers for Medicare & Medicaid Services, “Release: CMS Notice Regarding Split (or Shared) Evaluation and Management Visits and Critical Care Services from May 26, 2021, through December 31, 2021,” May 26, 2021, https://www.cms.gov/files/document/enf-instruction-split-shared-critical-care-052521-final.pdf.

5 Medicare Program; CY 2022 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Provider Enrollment Regulation Updates; and Provider and Supplier Prepayment and Post-Payment Medical Review Requirements, 86 Fed. Reg. 64,996 (Nov. 19, 2021), https://www.govinfo.gov/content/pkg/FR-2021-11-19/pdf/2021-23972.pdf.

6 Medicare Program; CY 2022 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies.

7 § 415.140 Conditions for payment: Split (or shared) visits, up to date as of March 11, 2024, https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-415/subpart-C/section-415.140.

8 American Medical Association, “CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202–99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes,” January 1, 2021, https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf.

9 42 C.F.R. § 415.140 Conditions for payment, Split (or shared) visits.

10 American Medical Association, “CPT® Evaluation and Management (E/M) Code and Guideline Changes,” January 1, 2023, https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf.

11 Centers for Medicare & Medicaid Services, CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies.

12 United States of America, ex rel. Caleb Hernandez & Jason Whaley, Relators v. Team Health Holdings INC., Team Finance, L.L.C., Team Health INC., & Ameriteam Services, L.L.C., Case 2:16-cv-00432-JRG, (E.D. Tex. Nov. 12, 2018).

13 Medicare & Medicaid Services, CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program, 88 Fed. Reg. 78,818 (Nov. 16, 2023), https://www.federalregister.gov/documents/2023/11/16/2023-24184/medicare-and-medicaid-programs-cy-2024-payment-policies-under-the-physician-fee-schedule-and-other.

14 American Medical Association, CPT Professional 2024 (Chicago, IL: American Medical Association, 2023).

15 Medicare and Medicaid Services, CY 2023 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Implementing Requirements for Manufacturers of Certain Single-dose Container or Single-use Package Drugs To Provide Refunds With Respect to Discarded Amounts; and COVID–19 Interim Final Rules, 87 Fed. Reg. 69,904 (Nov. 18, 2022), https://www.federalregister.gov/documents/2022/11/18/2022-23873/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other.

16 American Medical Association, “CPT® Evaluation and Management (E/M) Code and Guideline Changes.”

17 Medicare Program; CY 2022 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies.

18 Centers for Medicare & Medicaid Services, 1997 Documentation Guidelines for Evaluation and Management Services, accessed March 25, 2024, https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/97docguidelines.pdf; Centers for Medicare & Medicaid Services, 1995 Documentation Guidelines for Evaluation and Management Services, accessed March 25, 2024, https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/95docguidelines.pdf.

19 American Medical Association, CPT Professional 2022 (Chicago, IL: American Medical Association, 2021).

20 Centers for Medicare & Medicaid Services, “Release: CMS Notice Regarding Split (or Shared) Evaluation and Management Visits and Critical Care Services from May 26, 2021, through December 31, 2021.”

21 American Medical Association, CPT Professional 2021 (Chicago, IL: American Medical Association, 2020).

22 American Medical Association, “CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202–99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes.”

23 Centers for Medicare & Medicaid Services, “Nursing Facility Service (Codes 99304 – 99318).”

[View source.]