By: Sheila Haynes, CPC
Coding and Compliance Manager

Take notice and prepare for changes to the guidelines for billing split/shared services if your practice’s physicians and qualified health care professionals (QHP) regularly team up for hospital visits. The new guidelines go into effect on Jan. 1, 2022.

What is a Split/Shared Visit?

  • Definition of split (or shared) E/M visit is an E/M visit provided in the facility setting by a physician and an NPP in the same group.
  • The visit is billed by the physician or practitioner who provides the substantive portion of the visit.

What are the main considerations in the new guidelines?

  • By 2023, the substantive portion of the visit will be defined as more than half of the total time spent.
  • For 2022, the substantive portion can be history, physical exam, medical decision making, or more than half of the total time (except for critical care, which can only be more than half of the total time).
  • The treating provider who performs the “substantive portion” of the visit will bill the service
  • Split (or shared) visits can be reported for new as well as established patients, initial and subsequent visits, prolonged services as well as critical care services.
  • A modifier is required on the claim to identify these services to inform policy and help ensure program integrity — FS (Split [or shared] evaluation and management visit)
  • Documentation in the medical record must identify the two individuals who performed the visit. The individual providing the substantive portion must sign and date the medical record.
  • Split/shared facility services may be billed for encounters in any facility setting, including the emergency department and skilled nursing facilities.

What should your practice do to prepare?

  • Practices should focus on how to calculate the “substantive portion” of the visit
  • This is a unique approach to billing that will determine which practitioner bills the service and how much revenue the practice receives.

Calculating the “substantive portion” and how to bill

  • In 2022 – calculate the substantive portion of the visit based on time or the performance of documented key components.
  • In 2023 – calculate the substantive portion of the visit only based on time
  • To calculate based on time, both providers will need to document the time spent on the activities that qualify for time-based coding that was established for office/other outpatient visits (99202-99215). All activities must take place on the same day as the encounter with the patient
      • Preparing to see the patient (e.g., reviewing tests, external records)
      • Face-to-face encounter time; exam, counseling or educating a patient, family or caregiver
      • Reporting test results to a patient by phone
      • Ordering medications, tests or procedures
      • Documentation work performed after encounter on the same day
      • Care coordination (when not separately reportable)
      • Getting and/or reviewing separately obtained history
      • Referring the patient to and communicating with other health care professionals (when not separately reportable)
  • The encounter should be billed under the name and NPI of the clinician that spends the greatest amount of time (i.e., more than 50% of all activities)
  • Always append the new -FS (Split/Shared evaluation and management visit) modifier to the billed E/M service code

What to consider when choosing your billing options for 2022

  • For 2022 – If your practice chooses to calculate the substantive portion of the encounter based on the performance of the documented key components.
      • Per CMS, the clinician who bills the visit must perform the component in its entirety in order to bill under their NPI
      • The billing provider must also personally document what’s required for that component
      • While the component-based billing is an option for 2022 to assist practices in the transition to the time-based model that is effective Jan. 1, 2023, your practice should consider if the effort of training the providers and staff on the component-based coding is worth it for the brief time this option is available.
  • While CMS created the key component option for 2022, there are two statements in the final rule that may make time-based billing more attractive
      • A face-to-face encounter is not required. The billing clinician doesn’t have to see the patient. In response to several comments, CMS stated, “The substantive portion could be entirely with or without direct patient contact and will be determined by the portion of the time, not whether the time involves direct or in-person patient contact.”
          • This means that if the physician spends 20 minutes on activities that do not need to be performed face-to-face, such as ordering, interpreting test results, conferring with other physicians, or coordinating and the NPP spends 15 minutes with the patient getting a history, performing an exam and counseling the patient, the physician will be the billing provider/NPI for this service.
      • Timekeeping is an individual choice. CMS also received feedback about how it wanted practices to track time. CMS stated in the final rule, “We believe we should leave it to the discretion of individual practitioners and the groups they work in to decide how time will be tracked”.

The following table shows the CMS definition of substantive portion for both 2022 and 2023