Coding Corner: 2024 Update to Split/Shared Evaluation and Management Visit
Jolyn Taylor, MD, MPH
January 1, 2024, the Centers for Medicare and Medicaid (CMS) finalized their rule on the definition of the “substantive portion” of a split/shared Evaluation and Management (E/M) visits. A split/shared visit is an E/M encounter in which part of the care delivered is by a physician and part by a non-physician practitioner. This does not apply to trainees such as residents or fellows. This rule applies to care delivered in a facility setting, but does not apply to care delivered in a non-facility physician office (that would be ‘incident to’ care), a nursing home, or other non-facility locations. The provider who performs the “substantive” portion of the E/M visit may bill. The “substantive portion” is considered more than half of the total time spent by the physician or non-physician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making. Either time (which includes time spent by the provider billing, as well as the total time spent on the day of service as described below) or the medical decision making (to include number and complexity of problems addressed, amount and/or complexity of data to be reviewed and analyzed and risk of complications and/or morbidity or mortality of patient management) must be documented to justify the provider billing the split/shared E/M visit.
When billing by time, total time may be calculated based on any of the following:
- 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)
This CMS ruling follows what was initially planned as a transitional period for E/M changes, effective January 1, 2023, which also allowed billing by either time or medical decision making. CMS had originally proposed to move to an entirely time-based calculation of allocation of services by 2024, however, after consideration of feedback from the medical community, CMS ruled to continue to allow allocation of services based on either time or medical decision making.
Here are two examples of split/shared E/M billing:
- Dr. Gyn is rounding in the hospital on the inpatient service with PA Onc. During rounds, they see a 63-year-old patient with ovarian cancer admitted with carcinomatosis causing a partial small bowel obstruction and intractable pain. Dr. Gyn reviews the labs which include a CBC, CMP and CA-125. Dr. Gyn also independently reviews the CT scan obtained during hospitalization and determines it to show a multi-focal small bowel obstruction and progression of disease. Dr. Gyn counsels the patient on these results and has a discussion related to prognosis, rationale for not recommending surgery and options for medically optimizing her current symptoms, include pain. Dr. Gyn attests a note written by PA Onc, describing his/her assessment and plan of care and documents that he/she performed the substantive portion of the medical decision making and bills 99223 with the FS modifier.
- Dr. Gyn is seeing patients in clinic with PA Onc. There is a new patient who is a 36-year-old with a newly diagnosed complex pelvic mass. PA Onc sees the patient for 10 minutes to obtain the history and clarify the presenting symptoms. Dr. Gyn and Onc PA see the patient together for 8 minutes to perform a physical exam. Dr. Gyn then spends 30 minutes with the patient reviewing results and counseling the patient on further evaluation with imaging and laboratory as well as possible surgical options. Dr. Gyn also reviews outside records and completes the medical documentation the same day as the visit for an additional 20 minutes. Dr. Gyn bills 99205 with the FS modifier and documents that he/she spent 50 minutes with the patient or preparing for the visit for a total time of 68 minutes.
Jolyn Taylor, MD, MPH, is a gynecologic oncologist at MD Anderson Cancer Center in Houston, TX.
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