Author: Keisha Wilson CCS, CPC, CRC, CPB, CPMA, AAPC Approved Instructor
In recent years there has been an increase in the hiring of NPPs (Non-Physician Practitioners), also known as APP (Advanced Practitioner Professionals), to lessen physician burden and burnout. Organizations and private practices have employed NPP/APPs to assist providers with seeing patients and managing their care. When the physician and the NPP/APP both perform some part of the same visit, it is called shared or split services.
Definition of Split or Shared visits
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, by 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. Services may include both face-to-face and non-face-to-face activities.
Who is considered an APP to CMS?
- Physician Assistant (PA)
- Nurse Practitioner (NP)
- Clinical Nurse Specialist (CNS)
- Nurse Midwives (CNM)
On Hold
CMS (Centers for Medicare & Medicaid Services) has delayed implementation using total time as the “substantive” related to Split/Shared services encounters from January 1, 2023, to January 1, 2024. Therefore, 2022 was the transition period allowing the provider who performed the substantive portion of the visit to bill under their NPI.
Was I shocked when CMS announced the delay? Not at all! Organizations and physician-based practices spent most of 2022 scratching their heads about implementing the new changes into their EHR and what provider and NPP workflow would look like. Did it benefit the organization financially to have the NPP see more patients? Would providers only see new patients and NPP-established patients? How will the EHR capture who entered which portion of the note? When utilizing time, what if one provider saw the patient for five more minutes than the NPP? Who gets the credit?
In March of 2022, 19 physician organizations came together. They wrote a letter to CMS urging CMS to reverse their decision on the final rule, requiring the billing provider to spend more than 50% of the total time for the “substantive” portion.
The letter stated, “the undersigned organizations strongly urge CMS to discontinue it’s split/shared visits policy and not move forward with the transition set to take effect in 2023. To comply with the Agency’s requirements, some facilities have provided attestation statements for clarity to indicate who performed the substantive portion, or key component, of the visit. Adopting and implementing these attestations is an onerous task, but the most problematic is that physicians and other practitioners have little idea of what an adequate attestation may be for 2023. Even if attestation examples were provided in the upcoming Medicare Physician Fee Schedule rulemaking cycle, practices would be left with minimal time to educate physicians and other practitioners, and even the slightest mistake in reporting could result in a hefty penalty or deduction to reimbursement.”
What can be billed now for Split/Shared Services?
Before January 1 2022, Split Shared services were rendered by the NPP and the physician and typically billed by the physician. However, as of January 1, 2022, the physician or NPP who spends more than half the total time (the substantive portion) will bill for the primary E/M visit and the prolonged service codes when the service is furnished as a split/shared visit.
Per the CMS factsheet, the substantive portion of a visit may be met by any of the following:
- History.
- Performing a physical exam.
- Making a medical decision.
- Spending time (more than half of the total time spent by the practitioner who bills the visit).
Time
If utilizing Total Time in determining the level of service, the practitioner who provides the most patient care time. This includes both face-to-face and non-face-to-face qualifying time:
- Preparing to see the patient (i.e., review of tests)
- Obtaining and or reviewing separately obtained history
- Performing a medically necessary exam or evaluation
- Counseling and educating 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 patient/family/caregiver
- Care coordination (not separately reported)
Approved Locations for Split/Shared
- Inpatient (POS 21)
- Hospital-based clinics/Outpatient (POS 19,22)
- Emergency Department (POS 23)
- Critical Care
- Observation
- Skilled Nursing Facilities (POS 31)
Note: CMS clarifies that practitioners can bill independently but only if they specifically and fully furnish the service.
Split/Share services do not apply to the office (POS 11). Those in POS 11 would utilize incident to when all incident to criteria is met.
CMS clarifies that practitioners can bill independently but only if they specifically and fully furnish the service. For example, if a physician and NPP/APP are in different groups, each furnishes part of an E/M service, but only some of the visit is billable. The physician must conduct and complete their visit/documentation and may not rely on the NPP’s notes.
Skilled Nursing Facilities
Per the CMS manual, SNF E/M visits may be billed as split (or shared) visits if they meet the rules for split (or shared) visit billing discussed in our other manual sections, except for SNF E/M visits that are required to be performed in their entirety by a physician. NF visits do not meet the definition of split (or shared) services and, therefore, are not billable.
Critical Care
As of January 1, 2022, Split/Shared visits were allowed to be used for critical care visits, and the substantive portion for critical care services is defined as more than half of the total time spent by the physician and NPP. Per Medicare’s Claims Processing Manual, visits occur when the total critical care service time furnished by a physician and NPP in the same group on a given calendar date to a patient is summed, and the practitioner who furnishes the substantive portion of the cumulative critical care time reports the critical care service(s). when two or more practitioners spend time jointly meeting with or discussing the patient as part of a critical care service, the time can be counted only once to report the split (or shared) critical care visit.
Modifier
FS Modifier – Split (or shared) evaluation and management visit. FS Modifier must be appended to the claim to permit for identification and tracking of Split/Shared services between a physician and NPP/APP in the same group. Modifier FS should only be reported on E/M services.
Summary
It’s imperative to understand and know how to bill for Split/Shared services for any organization and medical practice, whether they see patients in the office or hospital setting. NPP/APPs are essential to care team members in patient management and documentation in either location. Organizations and practices hiring NPP/APPs should know the different required billing for NPP/APPs and what payers follow CMS guidelines. In addition, organizations will want to assess workflow and analyze the changes’ impact on their revenue. Split/shared will now depend on who provides the most substantive portion of the visit. We must stay tuned to see if CMS 2024 final rule will move forward as intended utilizing the total time as the determining factor for Split/Shared visits on January 1, 2024.
To schedule training on documentation and coding guidelines of Split or Shared services for your organization or private practice providers, email us today at info@kwadvancedconsulting.com, schedule a call or visit the website and fill out the “contact us” form.
Resources
https://www.chestnet.org/Newsroom/CHEST-News/2022/04/CMS-urged-to-rescind-APP-split-shared-policy
https://public-inspection.federalregister.gov/2021-23972.pdf
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
