ED Coding and Reimbursement Alert

The new rule for 2022 does apply to observation care, reps say.

As most emergency department staffers know, the rules around reporting split-shared visits changed in January. If a physician and a nonphysician provider (NPP) from the same ED group share an E/M visit, the person who performs “the substantive portion of the visit” should be listed as the billing provider.

However, that’s not all you need to know if you want to ensure that your split/shared visits are reported correctly. Read on for five quick tips shared by NGS Medicare’s Catherine K. Delli Carpini, BSN, RN, during the Part B payer’s March 17 webinar, “2022 CMS Evaluation and Management Updates.”

1. Split/Shared Visit Rules Changed for Facilities

Understanding how to report evaluation and management (E/M) codes appropriately is important, particularly when they’re split or shared among providers, Delli Carpini said. “The bulk of services paid by the Medicare program are the evaluation and management codes, which most (if not all providers) do at some point or another in their practice. So it’s really essential that everyone understands the way they work and this year,” she said.

She added that effective January 1, 2022, split/shared E/M visit rules changed for services provided in the facility setting by physicians and NPPs who work for the same group. But before you turn away from coding using this new strategy because you assume that the ED doesn’t apply to the “facility” setting, think again, she said.

“Facility setting means that in any facility — inpatient or outpatient — split/shared visit rules apply,” Delli Carpini noted. “They do not apply in the office setting. In the office setting, incident-to rules apply, and they’re a bit different than the split/ shared rules.” However, these rules do apply to emergency department visits because they are considered to be taking place within a facility, even though ED providers are classified as outpatient practitioners.

The split/shared visit rules wouldn’t apply in a freestanding urgent care center, however, because those are considered non-facility settings, and services rendered there should be reported with outpatient E/M codes. In those cases, incident-to rules would apply instead of the split/shared visit rules.

2. Know What ‘Substantive’ Means

Many providers have been confused by the word “substantive,” Delli Carpini said. “It simply means that of the two providers, the physician or the NP/PA, the person who performed the bulk of the work is considered the one who did the substantive portion of the visit,” she said.

The substantive portion can be based on work performed around the history, the physical exam, the medical decision making, or (when applicable, such as with observation services), you can choose the code using more than half of the total time spent with the patient, she said.

“When you’re using time to assess that substantive portion, the provider who spent and documented the most time is considered the substantive or the billing provider,” Delli Carpini noted. “It really is relatively simple.”

3. Don’t Forget Modifier FS

If you’re reporting split/shared services, you must append modifier FS (Split (or shared) evaluation and management visit) to the appropriate E/M code, Delli Carpini advised. “Modifier FS applies to split/shared E/M services used in the inpatient and the outpatient setting. So all of your inpatient and outpatient codes used within a facility apply to the split/shared idea that it can be performed collaboratively by a nurse practitioner, PA, and a physician. And whoever performs the most work is the substantive provider who will be the person under whose number the visit will be billed.”

4. Observation, Critical Care, Consults Can Be Split/Shared

In addition to ED and inpatient services, the split/shared coding rules also apply to observation, prolonged services, and consultations this year, Delli Carpini said. “Up until this year, the guideline from CMS was that consultations could not be split/shared. As of January 1 of this year, CMS has confirmed consultations can now be split/shared. Admission and discharge can be split/shared, and critical care can be split/shared.”

When it comes to admission and discharge, you must be aware of which providers are permitted to perform particular services before you can evaluate whether the split/shared rules apply, she added. Just because these rules are valid in admissions and discharges, that doesn’t mean every admission/discharge code can be billed by an NPP.

“An admission cannot be done solo by a PA or a nurse practitioner, unless the facilities’ rules allow that person to have full admitting privileges,” Delli Carpini noted. “Now, if a physician with admitting privileges is responsible for that admission, he or she can split/share that with a nurse practitioner or a PA, but the PA or nurse practitioner can do it on their own only if they have admitting privileges. So there’s been a little bit of confusion around those points.”

5. Documentation Should Identify Those Who Split/Share Services

The two people who are splitting or sharing a service should be clearly noted in the documentation, Delli Carpini said. In addition, the individual providing the substantive portion has to sign and date the medical record. Delli Carpini advised that best practice from a “medical review standpoint” is to have each contributing provider document their portion of the service, including time spent if the service is time-based. “Remember that the record has to be able to support the fact that there were two people contributing here. What did each person do, who were those people, and how much time did they spend doing it? So, although the guideline that’s definitive from CMS is saying the substantive person has to sign and date the record, we would encourage you to have your providers have both folks who are contributing sign and date so that you can support that record in the event of a medical review,” she added.