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Article Detail - JE Part B

Split or Shared Evaluation and Management Visits

Effective January 1, 2022, CMS has issued updated guidance on evaluation and management services that qualify as split or shared services by two providers who are in the same group. Per the CMS statement “A split (or shared) visit is an evaluation and management (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.”

  • For visits (other than critical care) furnished in calendar year 2022, substantive portion means one of the three key components (history, exam, or medical decision-making) or more than half of the total time spent by the physician and nonphysician practitioner (NPP) performing the split or shared visit.
  • For calendar year 2023 and forward, the new guidance indicates the substantive portion for all split or shared visits will be defined as more than half the cumulative total time of the physician and NPP.
  • Because critical care visits are time-based codes, the substantive portion will be based on more than half the cumulative total time in qualifying activities that are included in CPT® code 99291 and the units of CPT® code 99292 (as needed).
  • Facility setting for purposes of this section means institutional settings in which payment for services and supplies furnished incident to a physician or practitioner's professional services is prohibited under 42 CFR § 410.26(b)(1). Hospital or skilled nursing home are facility settings.
  • Split or shared visits are billable for new and established patients, in both initial or subsequent visits and for prolonged services.

For purposes of payment for these services, the following conditions apply:

  • Substantive portion of split or shared visit - In general, payment is made to the physician or nonphysician practitioner who performs the substantive portion of the split or shared visit.
  • Medical record documentation - Documentation in the medical record must identify the physician and nonphysician practitioner 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.
  • Face-to-face contact - For all split or 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.
  • Claim modifier - The designated modifier must be included on the claim to identify that the service was a split or shared visit.
  • Example:
    • Distinct Time: In accordance with the 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.
    • 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).
    • To bill split or shared subsequent hospital service, the billing practitioner reports CPT® code 99232 if basing the coding on time. If not using time, bill CPT® codes 99231-99233 as meets the key component level on which the coding is based.
    • Modifier - FS (split or shared E/M visit) must be appended to the E/M code on the claim.

CMS manual updates to 100-04, Chapter 12, Section 30.6.18.

MLN MM12543 - Internet-Only Manual Updates (IOM) for Critical Care, Split/ Shared Evaluation and Management Visits, Teaching Physicians, and Physician Assistants

            Last Updated Thu, 17 Mar 2022 16:40:32 +0000