Medicare providers in hospitals and skilled nursing facilities (SNFs) are adjusting to new split/shared services documentation and billing regulations rolled out by the Centers for Medicare and Medicaid Services (CMS) as part of the 2024 Medicare Physician Fee Schedule (MPFS) final rule. The most notable change within the new regulations, which took effect on Jan. 1, 2024, is the finalization of CMS’s definition of the “substantive portion” of a split/shared evaluation and management (E/M) visit.
First introduced in 2022 in response to public comments asking CMS to allow either time or medical decision-making (MDM) to serve as the substantive portion, the 2024 definition of split/shared services is:
“More than half of the total time spent by the physician or nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making,”
Understanding who is considered to have spent the substantive portion of the visit is crucial in 2024 as it determines who will bill Medicare for such visits.
The Definition in Action
The new split/shared services billing requirements apply only to services provided in hospital or SNF settings (no office visits) when patients are seen during a primary E/M visit by both a physician and a nonphysician practitioner (NPP) such as a physician assistant, advanced practice registered nurse, nurse practitioner, clinical nurse specialist, or other nonphysician provider. Under the previous year’s rule, physicians would typically bill for the time spent by any number of clinicians to see, examine, consult with, and treat the patient using an FS modifier to denote the shared charges. Now, however, the billing or listed provider must be the person who spent the majority of time or MDM on the patient encounter.
To determine who reports the split/shared visit and which code level is used, CMS relies on the list of activities included in CPT E/M Guidelines that count toward total time, according to The American College of Surgeons. Those activities include:
- Preparing to see the patient
- Obtaining and/or reviewing separately obtained history
- Performing a medically appropriate examination and/or evaluation
- Counseling and educating the patient, family, and/or caregiver
- Ordering medications, tests, or procedures
- Referring and communicating with other healthcare professionals, when those actions are not reported separately
- Documenting clinical information in the electronic or other health record
- Independently interpreting results that are not separately reported and communicating those results to the patient, family, and/or caregiver
- Care coordination that is not separately reported
According to CMS guidelines, physician and NPP time does not include the following activities:
- Performing other services that are reported separately
- Travel
- Teaching that is general and not limited to discussion required for management of a specific patient
Finally, the AACP reports that documentation under the 2024 split/shared services rules should identify both practitioners. However, the medical record should be signed and dated only by the billing practitioner.
Taking Action
Complying with the 2024 split/shared services regulations will necessitate adopting new coding and auditing workflows. Coders and auditors will also need to outline documentation processes to ensure appropriate documentation is captured during patient visits and MDM – physician vs. NPP – must be appropriately reported to ensure compliant billing for split/shared services. While CMS does not define “appropriate documentation,” Coding Intel shares that “the only way for a physician and NPP to describe his/her contribution to the service is to document an individual note describing the portion of the service (they) performed.”
Physicians and NPPs will need to be trained on these documentation needs, which will also necessitate updates to claim scrubber software. Finally, documentation processes must ensure time records don’t show overlaps between physicians and NPPs, who are likely to require credentialing with payors to obtain a billing identification number.
Minimizing Challenges
Successfully adjusting to 2024 split/shared services billing requirements calls for comprehensive education for auditors, coders, and providers, along with a proactive audit strategy and deployment of robust technology tools to support billing audits.
Given the broad impact of these new split/shared services policies, internal audit workflow tools capable of separating the servicing provider from the billing provider during the audit process would be a sound investment. These tools provide the granularity auditors need to identify instances when the service provider does not match with the service provided. They also enable an improved root cause analysis for ferreting out process errors and provide valuable feedback to informed targeted ongoing provider and coder education.
The 2024 split/shared services billing rules provide greater transparency into care processes and better align reimbursement. Nonetheless, impacted providers and organizations are understandably apprehensive over the potential impact they will have on day-to-day workflows, timely compensation, audit risks, and the bottom line – all of which can be minimized with a proactive strategy encompassing education, audits, and workflow tools.
About Shanta Lewis
Shanta Lewis, CPC, CRC, CPC-I is the Product Owner at MDaudit, a company that enables healthcare organizations to reduce compliance risk, improve efficiency, and retain more revenue streams by providing workflow automation, risk monitoring, and built-in analytics and benchmarking capabilities – all in a single integrated cloud-based platform.
