Coding Corner: Split/Shared Services | Jolyn Taylor, MD, MPH
Scenario: A patient with newly diagnosed ovarian cancer is admitted to the hospital. Prior to walking in to see her, I spend 10 minutes reviewing her notes from the Emergency Room, her labs and her imaging. KT, a physician assistant, sees the patient for 10 minutes to obtain additional history. KT and I then spend 30 minutes together reviewing her history in detail, asking about current symptoms and performing a physical exam. KT then steps out of the room and places orders for additional imaging for 5 minutes. I remain with the patient and spend 20 minutes answering questions related to her diagnosis, next steps in diagnostic evaluation and an overview of management of advanced ovarian cancer. At the conclusion of the visit, I evaluate how to bill for this split/shared visit.
In 2022 the Centers for Medicare & Medicaid Services (CMS) provided new guidance on how to bill for a split/shared visit with a NPP (nonphysician provider). A NPP is defined by Medicare as a nurse practitioner, physician assistant, certified nurse specialist or certified nurse midwife. A split/shared visit is an E/M visit performed in a facility setting that involves both a physician and NPP. Medicare will reimburse a visit billed by a physician at 100% but NPP billed visits will be reimbursed at 85%. Split/shared visit changes do not, however, apply to incident-to service interactions that occur in a non-facility location such as a physician’s office when separate from the hospital setting.
Currently the billing provider is determined by whoever performs the substantive portion of care for the patient. The substantive portion can be determined by either who spends more than half of the total time of the visit caring for the patient or who performs the entirety of the history, physical or medical decision making (MDM). Determining substantive portion by MDM or time will continue through 2023, due to a delay in implementation of the CMS policy that time alone will determine the billing provider., Therefore not until 2024 will time be used to determine the substantive portion of a visit. Qualifying actions that count toward time include any of the following: preparing to see a patient with review of prior results, obtaining a history, performing a physical exam, counseling and education patient/family, placing orders, documenting (when done on the day of the visit), communicating with other services/physicians for the care of the patient, independently interpreting test results and care coordination.
In the above clinical scenario, I spent a total of 30 minutes alone, KT spent 15 minutes alone and we spent 30 minutes jointly. Therefore, I would bill, and could bill by time for 75 minutes. The level of service for the visit can still be determined by either time or MDM even if the documentation to support who is the billing provider is done using time. In order to bill, I need to document the two medical practitioners who provided care (KT and myself) and who performed the substantive portion with an explanation of how that was determined. I will also need to append modifier FS to the claim to indicate that this was a split/shared visit.
Jolyn Taylor, MD, MPH, is a gynecologic oncologist at MD Anderson Cancer Center in Houston, TX.