By Linda Duckworth, CHC, CPC
Director, Provider Education & Advisory Services
For the first time ever, CPT guidelines officially addressed the split/shared concept for patient care, “physician(s) and other Qualified Healthcare Providers (QHPs) may act as a team in providing care for the patient, working together during a single E/M service”(CPT, 2024.) In their updates for 2024, the Editorial Panel included their thoughts on what constitutes a “Split or Shared” service when it comes to a care-team approach outside the office setting. Thankfully, CMS has confirmed that they will adopt the Panel’s instruction, reducing provider and coder burden (and angst) when it comes to sorting through the criteria for billing and documentation, making it a win-win for all!
Compliance at Work
Since physicians are typically reimbursed at a higher rate, it is imperative to understand the ins and outs of split/shared billing and the documentation requirements to avoid potential paybacks. The best approach to reducing risks to the practice is to partner with a team of professionals that specialize in regulatory challenges such as this. Ventra Health has experts you can count on for getting reliable feedback and education on your coding and documentation.
The Care Team
For this article’s purposes, our reference to a Qualified Healthcare Provider (QHP) will be limited to nurse practitioners and physician assistants.
To bill a split/shared service under the physician, the physician and QHP must be within the same group and working within the same specialty, and the physician must perform the “substantive portion.”
Determining the Billing Provider
When using medical decision-making (MDM) in lieu of time, according to CPT, “For the purpose of reporting E/M services within the context of team-based care, the performance of a substantive part of the MDM requires that the physician(s) or other QHP(s):
- Made or approved the management plan for the number and complexity of problems addressed at the encounter, and
- Takes responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management” (CPT, 2024.)
Documentation will have to reflect the above, and there is more to it than meets the eye. CPT goes into further detail by saying, “By doing so, a physician or other QHP has performed two of the three elements used in the selection of the code level based on MDM.” This means the billing provider has performed or approved two of the following three elements:
- The number and Complexity of Problems Addressed (COPA) at the encounter.
- The amount and Complexity of Data to be reviewed and analyzed.
- The risk of Complications and/or Morbidity or Mortality of Patient Management.
Attributing Data Towards an E/M Level
If the amount and/or complexity of data is one of the two components used to determine the E/M level, there are certain stipulations:
- Category 1 options do NOT have to be personally performed by the billing provider:
- Using an independent historian
- Reviewing external records
- Ordering unique tests or reviewing unique test results
- Category 2 and 3 MUST personally be performed by the billing provider:
- Independent interpretation of images, tracings, tests
- Discussion of the management plan or test interpretation with another provider or appropriate source
The medical record must clearly express that the extended efforts for category two and/or three were made personally by the billing provider.
Proving Your Work
Simply co-signing a note could be rife with challenges under payer audit since each may have their own documentation expectations, and even CMS has discrepancies. In the 2022 Final Rule, released November 19, 2021, (42 CFR 415.140,) they state that physicians “may review and verify (sign and date) the medical record for the services they bill, rather than re-document notes in the medical record made by physicians, residents, nurses, and students (including students in therapy or other clinical disciplines), or other members of the medical team.” Yet, in the 2024 Final Rule, page 78985, they lead us to believe that the physician has ownership of personally documenting their contribution, “we expect that whoever performs the MDM and subsequently bills the visit would appropriately document the MDM in the medical record to support billing of the visit.”
To improve credibility, Ventra Health suggests that the billing provider create an attestation template, then expand on it. Add patient-specific observations for each encounter. Attach tailored comments regarding the patient’s status, any personal interpretation of data, what the assessment and/or plan involves, or discussions had with other providers.
According to CPT and CMS, when comments about the substantive portion are added, the billing provider is taking “responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management.”
The billing provider must sign the note. There is no wiggle room on that topic.
Modifier FS
Add modifier FS to each split/shared E/M code for Medicare claims.
What’s Next and How Ventra Health Can Help
Ventra Health takes compliance very seriously. We encourage providers and coders to monitor changes to instructions by payers, including CMS. This article was based on information that was current at the time it was written, and portions of the article may contain interpretations that could differ from a payer. Stay tuned to our Compliance Blog Series to learn more about changes in regulations and guidelines.
In case you missed it, check out our previous post in the series: The Untold Challenges of E/M Risk Determinations
Learn more about the E/M Coding Guidelines
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Contact UsSources:
American Medical Association (AMA) CPT 2024 Professional Edition
American Medical Association (AMA) CPT Changes 2024, an Insider’s View
CMS’ Calendar Year (CY) 2024 Medicare Physician Fee Schedule Final Rule, “For CY 2024, we are finalizing a revision to our definition of “substantive portion” of a split (or shared) visit to include the revisions to the Current Procedural Terminology (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.”
