split shared visits 2024

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E/M Coding and Billing Res...
Split-Shared EM Visits

Reporting Split/Shared E/M Visits in 2024

Beginning January 1, 2024, the Centers for Medicare & Medicaid Services (CMS) will implement a new split (or shared) evaluation and management (E/M) billing policy for E/M visits provided in part by a physician and in part by a nonphysician practitioner (NPP). The billing provider for such visits will be the physician or NPP who furnished the “substantive portion” of the visit. CMS defines “substantive portion” to mean more than half of the total time spent by the physician or NPP performing the split/shared visit or the substantive part of the medical decision making (MDM) during the split/shared visit.

A split/shared visit is an E/M visit in a hospital or other facility setting that is performed in part by both a physician and an NPP who are in the same group practice. A split/shared E/M visit may be provided to a new or established patient for an initial or subsequent visit.

No. This new split/shared E/M visit reporting policy applies only to those furnished in a facility setting. In a nonfacility setting, such as a physician’s office, different reporting rules apply when an NPP provides some or all of an E/M visit and the physician bills for the visit. This type of E/M visit is referred to as an "incident-to" service.

Medicare defines an NPP as a nurse practitioner, physician assistant, certified nurse specialist, or certified nurse midwife. All of these practitioners may independently report E/M services if they are legally authorized and qualified to furnish an E/M service in their state. NPPs who care for Medicare patients in a facility must enroll in the Medicare program to bill for the services they provide.

CMS has yet to provide a definition of "same group" at this time, but has indicated that a physician and an NPP must work jointly to furnish all of the work related to the E/M in circumstances when a split/shared visit is appropriately billed. If a physician and NPP are in different groups, the physician and NPP would be expected to bill independently and only for the services each fully furnishes.

CMS has adopted the following Current Procedural Terminology (CPT ® ) guidelines for reporting a split/shared E/M visit:

If the physician or other QHP 1 performs a substantive portion of the encounter, the physician or other QHP may report the service. If code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service. For the purpose of reporting E/M services within the context of team-based care, performance of a substantive part of the MDM requires that the physician(s) or other QHP(s) made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management. By doing so, a physician or other QHP has performed two of the three elements used in the selection of the code level based on MDM. If the amount and/or complexity of data to be reviewed and analyzed is used by the physician or other QHP to determine the reported code level, assessing an independent historian’s narrative and the ordering or review of tests or documents do not have to be personally performed by the physician or other QHP because the relevant items would be considered in formulating the management plan. Independent interpretation of tests and discussion of management plan or test interpretation must be personally performed by the physician or other QHP if these are used to determine the reported code level by the physician or other QHP. 2

CMS relies on the list of activities included in CPT E/M Guidelines that count toward total time for purposes of who reports the split/shared visit and for the level of code selected. Based on these guidelines, physician/NPP time includes the following activities:

Preparing to see the patient (such as review of tests)
Obtaining and/or reviewing separately obtained history
Performing a medically appropriate examination and/or evaluation
Counseling and educating the patient/family/caregiver
Ordering medications, tests, or procedures
Referring and communicating with other health care professionals (when not separately reported)
Documenting clinical information in the electronic or other health record
Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
Care coordination (not separately reported)

Physician/NPP time does not include the following activities:

Performance of other services that are reported separately
Teaching that is general and not limited to discussion that is required for the management of a specific patient

No. For all split/shared E/M visits, only one of the practitioners must have face-to-face (in-person) contact with the patient, but it does not necessarily have to be the practitioner who performs the substantive portion and bills for the visit. When reporting a split/shared visit using total time, the substantive portion could be provided entirely with or without direct patient contact and will be determined based on the proportion of total time, not whether the time involves direct or in-person patient contact.

Yes. If code selection is based on total time on the date of the encounter, the service is reported by the physician/NPP who spent the majority of time performing the service.

CMS has not yet released specific documentation requirements for reporting a split/shared E/M visit. However, it is best practice that the medical record identify the two practitioners who performed the split/shared visit, the activities each practitioner performed, and the time spent by each practitioner. In addition, the individual who performed the substantive portion—and therefore bills the visit—must sign and date the medical record. CMS has emphasized that, although any member of the medical team may enter information into the medical record, only the reporting provider may review and verify notes made in the record by others for the services the reporting clinician furnishes and bills.

The new split/shared E/M visit guidelines indicate that performance of a substantive part of the MDM requires that the physician or NPP who will bill the visit made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or the morbidity or mortality of patient management. By doing so, a physician or NPP has performed two of the three elements used in the selection of the code level based on MDM.

Yes. CMS requires that HCPCS modifier –FS ( Split or shared E/M visit ) be appended to the facility claims for split/shared E/M visits, no matter if the physician or NPP bills for the visit. This modifier does not apply to incident-to office visits.

No. Critical care E/M services (e.g., CPT codes 99291-99292) are reported based solely on time. MDM is not a component of these CPT codes.

Please note that the reporting details above are suggestions only and should not be construed as official coding/billing rules.

1 CPT, in general, refers to NPPs as other qualified healthcare professionals (QHPs). With respect to reporting split/shared services in a facility setting, NPPs and other QHPs are synonymous.

2 2024 CPT Codebook, pg. 6.

Split/Shared Billing: 2024 Medicare Physician Fee Schedule Final Rule

On November 2, 2023, the Centers for Medicare & Medicaid Services (CMS) issued the calendar year 2024 Medicare Physician Fee Schedule Final Rule. Within it, CMS announced it will be adopting the American Medical Association (AMA) definition of “substantive portion” for split/shared evaluation and management (E&M) inpatient visits so that the split/shared policy aligns with CPT guidelines.

The 2024 CPT E&M guidelines indicate the following:

A split/shared encounter is one in which a physician and other qualified healthcare professional (QHP) act as a team in providing care for the patient, working together during a single E&M service.
The split/shared visit guidelines are applied to determine which professional may report the service. If the physician or other QHP performs a substantive portion of the encounter, the physician or other QHP may report the service.

Accordingly, per the final rule, the definition of substantive portion will be more than half of the total time spent by the physician and nonphysician practitioner (NPP) performing the split/shared visit, or a substantive part of the medical decision-making (MDM) as defined by CPT.

The most notable change is that CMS no longer allows the documentation of history or exam in its entirety as a measure of determining which provider performed the substantive portion, since these are not included in the E&M split/share CPT code definitions.
One key exception to the final rule definition change concerns critical care visits. Critical care visits do not use MDM, only time. As such, for critical care visits, the substantive portion will continue to mean more than half of the total time spent by the physician and NPP performing the split/shared visit.

CMS has finalized the policy for 2024 to alleviate administrative challenges that would otherwise burden practices investing time and resources in preparing for potential policy changes that are repeatedly postponed. However, CMS has emphasized that billing under the physician for split/shared visits must include documentation for how the physician participated in the care management plan, including whether they made or approved the plan for the number and complexity of problems and take responsibility for the plan and its inherent risk of complications.

It is worth noting that CMS received a variety of feedback on finalization of the policy. Some commentors requested that CMS withdraw the substantive portion policy altogether while others asked that it continue the current policy to allow use of the three key components (history, time, MDM) or time to determine who bills for the visit. Industry reaction notwithstanding, the substantive portion policy is here to stay in 2024.

ECG can provide strategies to help your organization be proactive in addressing the regulatory changes of the final rule.

Visit our Center for Split/Shared Success for continuing updates and advice.

Center for Split/Shared Success

Edited by: Matt Maslin

Published December 27, 2023

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