In the 2022 Medicare Physician Fee Schedule Final Rule (Final Rule), the Centers for Medicare & Medicaid Services (CMS) announced new rules for split/shared visits in the facility setting. For 2022, such visits may be billed under the National Provider Identifier (NPI) of the physician or non-physician practitioner (NPP) who either (1) documents the support for the history, exam, or medical decision-making for the visit, or (2) provides more than 50% of the service time. For 2023, split/shared visits must be billed under the NPI of the individual who provides more than 50% of total visit time.
These new rules could significantly impact Medicare reimbursement for physician practices that use NPPs in facility settings. For evaluation and management (E/M) visits jointly furnished by a physician and NPP in the same group practice in a facility setting (e.g., place of service [POS] 21 inpatient hospital or 22 provider-based clinic), CMS has permitted the visit to be billed under the physician’s NPI. Specifically, CMS’ split/shared visit rule has required that a physician perform only some portion of the E/M visit in order to bill that service under the physician’s NPI. Thus, the practice received full payment for the visit rather than the 85% of the Physician Fee Schedule rate paid for services billed under an NPP’s NPI.
In the Final Rule, CMS clarified and made several changes to its rules for split/shared visits:
- The split/shared visit rules do not apply to office visits (place of service 11); instead, these visits may be billed ‘incident to” if the requirements are satisfied (established patient, established plan of care/condition, direct supervision). CMS has signaled that it will be reviewing the incident to rules in future rulemaking.
- CMS now will permit split/shared visits to be reported for new patients as well as established patients, for initial as well as subsequent visits, for critical care services, for prolonged E/M visits, and for skilled nursing facility/nursing facility E/M visits (other than those required to be performed in their entirety by a physician).
- CMS will require the use of a new modifier (yet to be identified) to identify all claims for split/shared visits.
- Documentation in the medical record must identify the two individuals (physician and NPP) who performed the visit.
- A split/shared visit must be billed under the NPI of the individual who performed the substantive portion of the visit. That individual also must sign and date the medical record.
- For 2022 only, split/shared visits may be billed under the physician’s NPI if (1) the medical record documentation indicates the physician performed one of the three key components (history, exam, or medical decision-making) in its entirety, or (2) more than half of the total time for the visit was spent by the physician. Otherwise, the visit must be billed under the NPP’s NPI. (For critical care services, only time may be used.)
- Beginning in 2023, only time will be used to determine the substantive portion of the visit.
Table 26 in the Final Rule summarizes these requirements:
|
E/M Visit Code |
2022 Definition of Substantive Portion |
2023 Definition of Substantive Portion |
|
Other Outpatient Visits (excluding Office Visits) |
History, or exam, or medical decision-making (MDM), or more than half of total time |
More than half of total time |
|
Inpatient/Observation/ Hospital/Nursing Facility |
History, or exam, or MDM, or more than half of total time |
More than half of total time |
|
Emergency Department |
History, or exam, or MDM, or more than half of total time |
More than half of total time |
|
Critical Care |
More than half of total time |
More than half of total time |
Many practices now have an NPP perform initial rounds in the hospital, followed by a physician briefly seeing each patient later in the day. These practices now bill these services under the physician’s NPI and thus receive 100% of the Physician Fee Schedule rate. Going forward, however, it is unlikely the time spent by the physician will exceed the NPP’s time. Thus, these services will have to be billed under the NPP’s NPI, and the practice’s reimbursement will be reduced by 15%.
Compliance tips:
- Only apply these rules to Medicare claims reporting. Monitor other payers for their split/shared visit requirements, which are usually a part of the payer’s incident to policy.
- Review physician and NPP contracts for potential impacts to compensation as the billing for these services will likely shift to the NPP. Work relative value unit (wRVU) capture for these providers will likely be different from what was anticipated during the compensation design.
- Billing provider selection:
- Time-based: Select the billing provider based on the predominance (more than 50%) of time spent.
- E/M guidelines-based (2022 only): Select the physician only if history, exam, or MDM are fully documented in support of the code to be reported.
If documentation is lacking from the physician, including time or a full component, report the code under the NPP’s NPI.
- Code selection:
- Time-based: Select the level of code based on 1995 or 1997 E/M documentation guidelines. Note that supporting this time requires documentation of counseling and/or coordination of care exceeding 50% of the physician’s unit or floor time focused on the patient. Use of total time is recommended.
- E/M guidelines-based: Use the documentation of both providers per the 1995 or 1997 E/M guidelines key components to select the level of service supported.
- Ensure Medicare enrollment for NPPs is active and accurate.
- Monitor Medicare Administrative Contractor (MAC) guidance on the application of this new policy.
- Use this PYA checklist to evaluate compliance with the new rules:
|
|
Split/Shared Visit Checklist |
|
1.0 |
Place of Service |
|
1.1 |
The visit should take place in one of the following settings: · Outpatient (excluding Office) · Inpatient · Observation · Hospital · Skilled Nursing Facility/Nursing Facility · Emergency Department · Critical Care (type of care) |
|
2.0 |
Provider Employment Status |
|
2.1 |
The Physician and Non-Physician Practitioner (NPP) should be employed by the same group (same tax ID). |
|
3.0 |
Substantive Portion of Visit (Billing NPI) |
|
3.1 |
CY2022: Bill under the physician’s NPI if (1) medical record documentation indicates the physician performed one of the three key components (history, exam, or medical decision-making) in its entirety, or (2) the physician performed more than half of total visit time; otherwise, bill under the NPP’s NPI. (For critical care services, only time may be used.) |
|
3.2 |
CY2023: The visit should be billed by the provider performing more than half of the total visit time. |
|
4.0 |
Modifier |
|
4.1 |
The claim should include the modifier defined by Medicare to describe the visit as split/shared. |
|
5.0 |
Documentation |
|
5.1 |
Documentation in the medical record must identify the two individuals who performed the visit. |
|
5.2 |
The individual who performed the substantive portion must sign and date the medical record. |
For related information, view our webinar “Timely, Tough, or Tricky – Physician Comp and FMV Topics | Group Practice Exception Changes and APPs”.
If you require assistance relating to E/M documentation and coding compliance, or with any matter involving compliance, valuation, or strategy and integration, one of our executive contacts would be happy to assist. You may email them below, or call (800) 270-9629.
