Split (or shared) E/M visits refer to evaluation and management visits performed in part by a physician and in part by other nonphysician practitioners in hospitals and other institutional settings. Physicians and nonphysician practitioners (NPP) performing the visits are in the same group practice, in accordance with 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. The work provided may be both face-to-face and non-face-to-face. Payment is made to the practitioner who performs the substantive portion of the visit.
Facility setting means an institutional setting in which payment for services and supplies furnished incident to a physician or practitioner’s professional services is prohibited under Medicare regulations.
For CY 2024, CMS finalized the revision to the definition of “substantive portion” of a split (or shared) visit to include the revisions to the CPT guidelines, such that for Medicare billing purposes, the “substantive portion” means 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. In other words, Medicare will allow time or medical decision making to serve as the substantive portion of a split (or shared) visit.
During the transitional years, 2022 and 2023, except for critical care visits*, the substantive portion can be one of the three key E/M visit components (history, exam, or medical decision-making [MDM]), or more than half of the total time spent by the physician and NPP performing the split or shared visit. In other words, for calendar year 2022 and 2023, the practitioner who spends more than half of the total time, or performs the history, exam, or MDM can be considered to have performed the substantive portion and can bill for the split or shared E/M visit.
When one of the three key components is used as the substantive portion in 2022 and 2023, the practitioner who bills the visit must perform that component in its entirety to bill.
*For critical care visits, starting for services furnished in CY 2022, the substantive portion will be more than half of the total time.
When the practitioners jointly meet with or discuss the patient, only the time of one of the practitioners can be counted.
Drawing on the CPT E/M guidelines, except for critical care visits, the following listing of activities can be counted toward total time for purposes of determining the substantive portion, when performed and whether or not the activities involve direct patient contact:
Preparing to see the patient (for example, 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)
Practitioners cannot count time spent on the following:
The performance of other services that are reported separately
Travel
Teaching that is general and not limited to discussion that is required for the management of a specific patient
For all split or shared visits, one of the practitioners must have a face-to-face (in-person) contact with the patient, but it does not necessarily have to be the physician nor the practitioner who performs the substantive portion and bills for the visit. The substantive portion can be entirely with or without direct patient contact, and is determined by the proportion of total time, not whether the time involves patient contact.
Beginning January 1, 2023, the physician or practitioner who spent the substantive portion will bill for the primary E/M visit and the prolonged service code(s) when the service is furnished as a split or shared visit, if all other requirements to bill for split or shared services are met. The physician and NPP will add their time together, and whoever furnished more than half of the total time, including prolonged time, (that is, the substantive portion) will report both the primary service code and the prolonged services add-on code(s), assuming the time threshold for reporting prolonged services is met.
During the transitional calendar year 2022, when practitioners use a key component as the substantive portion, there will need to be different approaches for hospital outpatient E/M visits than other kinds of E/M visits:
For shared hospital outpatient visits where practitioners use a key component as the substantive portion, prolonged services can be reported by the practitioner who reports the primary service, when the combined time of both practitioners meets the threshold for reporting prolonged hospital outpatient services (HCPCS code G2212).
For all other types of E/M visits (except emergency department and critical care visits), prolonged services can be reported by the practitioner who reports the primary service, when the combined time of both practitioners meets the threshold for reporting prolonged E/M services other than office and other outpatient E/M visits (60 or more minutes beyond the typical time in the CPT code descriptor of the primary service). (Emergency department and critical care visits are not reported as prolonged services).
Split or shared visits may be billed for new and established patients, as well as for initial and subsequent visits, that otherwise meet the requirements for split or shared visit payment.
Split or shared visits are furnished only in the facility setting, meaning institutional settings in which payment for services and supplies furnished incident to a physician or practitioner’s professional services is prohibited under our regulations at 42 CFR § 410.26(b)(1).
Accordingly, split or shared visits are billable for E/M visits furnished in hospital and skilled nursing facility (SNF) settings. Visits in these settings that are required by our regulations to be performed in their entirety by a physician are not billable as split or shared services. For example, our Conditions of Participation require certain SNF visits to be performed directly and solely by a physician; accordingly, those SNF visits cannot be billed as a split or shared visit (see CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, section 30.6.13).
Documentation in the medical record must identify the physician and NPP who performed the visit. The individual who performed the substantive portion of the visit (and therefore bills for the visit) must sign and date the medical record.
Critical care visits may be furnished as split or shared visits. Specifically, the billing practitioner bills the initial service (CPT 99291) and any add-on codes(s) for additional time (CPT 99292). In the context of critical care, split or shared 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).
Modifier -FS (split or shared E/M visit) must be appended to the critical care CPT code(s) on the claim.
The same documentation rules apply for split or shared critical care visits as for other types of split or shared E/M visits. Consistent with all split or shared visits, 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 for purposes of reporting the split or shared critical care visit.
Physicians in the same group who are in the same specialty must bill and be paid for services under the Physician Fee Schedule as though they were a single physician. If more than one E/M visit is provided on the same date to the same patient by the same physician, or by more than one physician in the same specialty in the same group, only one E/M service may be reported, unless the E/M services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. This general policy is intended to ensure that multiple E/M visits for a patient on a single day are medically necessary and not duplicative.
However, in situations where a patient receives another E/M visit on the same calendar date as critical care services, both may be billed (regardless of practitioner specialty or group affiliation) as long as the medical record documentation supports: 1) that the other E/M visit was provided prior to the critical care services at a time when the patient did not require critical care, 2) that the services were medically necessary, and 3) that the services were separate and distinct, with no duplicative elements from the critical care services provided later in the day. Practitioners must use modifier -25 (same-day significant, separately identifiable E/M service) on the claim.
Critical care visits are sometimes needed during the global surgery period of a procedure, whether pre-operatively, on the same day, or during the post-operative period. In those cases where a critical care visit is unrelated to the procedure with a global surgical period, critical care visits may be paid separately in addition to the procedure. When the critical care service is unrelated to the procedure, append the modifier -FT (unrelated E/M visit on the same day as another E/M visit or during a global procedure [preoperative, postoperative period, or on the same day as the procedure).
Modifiers must be reported on claims for split or shared visits, to identify that the service met criteria for processing and potential separate payment. The table below list these modifiers.
Modifier |
Definition |
Use with |
Append to |
Modifier -FS |
Split or shared E/M visit |
Split or shared services |
E/M code |
Modifier -FT |
Unrelated E/M visit on the same day as another E/M visit or during a global procedure (preoperative, postoperative period, or same day as procedure) |
Critical care unrelated to surgical procedure during global period |
Critical care code |
Modifier -25 |
Significant, separately identifiable E/M service on same day |
Critical care on same day as another E/M visit* |
Critical care code |
Distinct time: In accordance with the CPT E/M guidelines, only distinct time can be counted. When the practitioners jointly meet with or discuss the patient, only the time of one of the practitioners can be counted.
If the NPP first spent 10 minutes with the patient and the physician then spent another 15 minutes, their individual time spent would be summed to equal a total of 25 minutes. The physician would bill for this visit since they spent more than half of the total time (15 of 25 total minutes). If, in the same situation, the physician and NPP met together for five additional minutes (beyond the 25 minutes) to discuss the patient’s treatment plan, that overlapping time could only be counted once for purposes of establishing total time and who provided the substantive portion of the visit. The total time would be 30 minutes, and the physician would bill for the visit since they spent more than half of the total time (20 of 30 total minutes).
To bill as a split or shared subsequent hospital service, the billing practitioner reports CPT code 99232 if basing the coding on time. For calendar year 2022, if not using time, bill CPT codes 99231–99233 as meets the key component level on which the coding is based – the billing practitioner must perform of one of the three key E/M visit components of history, exam or medical decision making.
Modifier -FS (split/ shared E/M visit) must be appended to the E/M CPT code on the claim.
Note: The modifier identified by CPT for purposes of reporting partial services (modifier -52 [reduced services]) cannot be used to report partial E/M visits, including any partial services furnished as split or shared visits. Medicare does not pay for partial E/M visits.
Note: The modifier identified by CPT for purposes of reporting partial services (modifier -52 [reduced services]) cannot be used to report partial E/M visits, including any partial services furnished as split or shared visits. Medicare does not pay for partial E/M visits.
Loading...
