When a split/shared visit takes place, both the physician and the nonphysician provider (NPP) perform part of an E/M visit in the facility setting. The tricky part comes in when determining which provider should actually report the claim for the service.
Check out a few tips so you can ensure your practice is following the split/shared billing rules in 2023.
Confirm Where the Visit Took Place
Split/shared visits aren’t an option in the physician’s practice—for those visits, you should instead turn to incident-to billing. If, however, the visit took place in the hospital (inpatient, outpatient or emergency department) or a skilled nursing facility (SNF), you should be able to use the split/shared rules as long as the NPP and the physician are employed by the same group practice. Keep in mind, however, that some SNFs have non-skilled areas, and split/shared does not apply to non-skilled nursing care.
In addition, some services must be performed by physicians only, according to the law. For instance, a SNF admission or readmission must typically be performed by a physician, and so split/shared billing wouldn’t apply to those services.
In 2023, critical care can also be billed split/shared by adding together the critical care time that the NPP and the MD spent. You’ll choose the most accurate critical care code using that total time, and bill it under the provider who performed the substantive portion.
What’s the ‘Substantive Portion?’
No matter where the split/shared visit occurred, the documentation should be very clear about who performed the substantive portion of the visit, because you’ll submit the claim under that provider’s NPI. But how can you tell?
Here’s how: CMS indicates that the substantive portion can be one of the three key components of history, examination, and medical decision making (MDM)—OR more than half the total time of the visit. Of course, you no longer select E/M codes based on the history, exam and MDM, but you’ll still use those elements to determine the substantive portion.
Looking ahead: In 2024, it’s likely that the substantive portion will be determined based solely on who spent more than half the total time, but that proposal has not yet been finalized by CMS.
Make Sure Both Providers Are Identified
If you’re billing a split/shared visit, the documentation must identify both providers, and the one who performed the substantive portion of the visit must sign and date the record.
Tip: Most compliance experts suggest that both providers should sign and date the record if the electronic system allows it, just for cleaner recordkeeping. But CMS truly requires only the billing provider to sign and date it no matter what.
Don’t Forget Modifier FS
If you report a split/shared visit, the E/M code must have modifier FS appended to it. This tells the payer that even though you’re reporting under the NPI of one particular provider, the actual visit was performed by more than one person.
Check These Examples
Now that you’ve got the hang of the split/shared rules for 2023, check out these examples to see if you can determine which provider should bill the service.
Example 1: The NPP performs a comprehensive history and exam, and creates an assessment and plan. The MD writes, “I saw and examined the patient with the NPP. I agree with his history and physical exam. The assessment and plan are my own. I have made corrections/additions where appropriate. If there is concern for meningitis, I would recommend lumbar puncture.”
Solution 1: Even though the MD says the assessment and plan are his own, there’s no documentation to show that they are actually the physician’s own. The final sentence could be seen by an auditor as the MD not performing any MDM, but leaving it to the NPP to make the medical decisions. In this case, the NPP should bill the service.
Example 2: The NPP documents a comprehensive history and exam, while the MD documents an assessment and plan that states, “Type II NSTEMI in the setting of significant anemia and possible GI bleed, with high probability of significant coronary artery disease. Given acuity of anemia, will treat medically at this time, and will likely proceed with further ischemic evaluation once stable. Will start high-dose statin. Blood pressure currently limiting initiation of beta blockaded/ACEI. No DAPT/heparin at this time given GI bleed. GI consulted and considering endoscopic evaluation. Echo showed poor image quality, but there is at least moderate to severe aortic stenosis noted. Hypertension requires vasopressors at this time.”
Solution 2: The MD performed the entire MDM portion of the visit, thus qualifying the record to be billed under the physician’s NPI.
Seeking more clarity about how to report split/shared visits? Let expert Kim Huey, MJ, CHC, CPC walk you through the ins and outs of these confusing services. During her 90-minute online training, “Get Paid 15% More, 2023 Split/Shared & Incident-to Rule,” Kim will help you master the 2023 rules and prepare for 2024. Register today!
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