As a result of the 2021 changes to Evaluation and Management (EM) Service Codes and the 2022 Medicare Physician Fee Schedule (MPFS) Final Rule, we are beginning to have a good understanding of the revisions to the policies surrounding the Split or Shared Services. The Center for Medicare and Medicaid Services (CMS) defines Split or Shared Services as those performed in combination by a physician and a Non-Physician Practitioner (NPP) who belong to the same group. The service must be performed in a facility setting like a hospital or skilled nursing facility. The provider who performs the substantive portion of the visit must bill under his or her National Provider Identifier (NPI).
Defining the Substantive Portion
CMS currently defines the substantive portion as more than half of the total time, but there will be a transition of this policy over the next two years. Keep in mind that inpatient visits still require the three key components of history, exam, and medical decision-making (MDM) or time. The exception to this is Critical Care Services, which is always based on time. In 2022, the substantive portion includes the history, physical exam, and MDM, or more than half the total time. For 2023, only the substantive portion of the visit based on time will be accepted. This may be an indication of more changes coming to the remainder of the EM codes in the future.
Accepted Settings and Services
Split or Shared Services can be performed in many settings and can be for several different services. Settings include inpatient, outpatient, observation, emergency departments, critical care, and nursing facilities. It is not acceptable in an office setting, place of service 11, but providers can use incident-to services when the guidelines are followed. The services include new and established patient visits, initial and subsequent hospital visits, as well as prolonged services. The practitioner billing the substantive portion may combine the individual time of both providers to meet the time threshold for a prolonged visit.
Documentation
The visit documentation needs to clearly indicate the names of both providers sharing the visit, and each must have their portion individually documented. The record must confirm that at least one of the providers had a face-to-face (in person) encounter with the patient and overlapping time by both providers cannot be used for billing. The individual providing the substantive portion must sign and date the note.
Coding for Split or Shared Services
CMS created the Modifier FS for reporting Split or Shared services. New codes usually become active at the start of the year, but that doesn’t mean that your Medicare Administrative Contractors (MACs) and other commercial payers are ready to process them. There is sometimes a delay in their programing, so you may have to appeal a rejection or denial.
Have additional questions regarding Split or Shared Services policies? We’re here to help. Contact Laura Summy at 234-466-1150 to schedule an initial discussion.
Tobi Klein, CPC, RCC is a Coder II at Medic Management Group and brings over 24 years of experience in the healthcare industry. She has been a chart auditor and coder for the coding department since 2012, providing individual physician reports and educating her clients based on their particular level of documentation need.