Gastroenterology Coding Alert

Both the Centers for Medicare & Medicaid Services (CMS) and CPT® have revised the billing rules for split or shared services between a physician and advanced practice provider (APP) several times in recent years, and 2024 added another wrinkle when defining the substantive portion and distinct time.

Learn how to correctly bill split/shared services using distinct time.

Examine the E/M Guidelines

Determining which provider could bill for split/shared evaluation and management (E/M) services has evolved over the past five years. Up to 2021, the physician could bill for the shared service if they performed the substantive portion of the service or if they performed a portion of the history, physical examination, or medical decision making (MDM).

In 2022 and 2023, the substantive portion of a service was defined as:

• Spending more than half of the total time providing the service, or
• Performing the history, physical exam, or MDM in its entirety

In 2024, the AMA established a separate substantive portion definition in the CPT^® code set. Now, the AMA counts the substantive portion in the following ways :

• When using time-based coding, the substantive portion is defined as more than 50 percent of the time providing the service on the date of the encounter. This includes face-to-face and non-face-to-face time
• When using MDM coding, the provider who made or approved the management plan for the number and complexity of problems addressed at the encounter must perform two-thirds of the elements needed to select a level of MDM

When coding using MDM, the provider who bills for the substantive portion must then assume responsibility for the plan and the associated risks.

If you decide to bill using time-based coding, your providers should include documentation for the distinct time they spent with the patient providing services. CPT® guidelines define distinct time in the same way you’d bill based on time. Professional time for a physician or other qualified healthcare professional (QHP) includes:

• “Preparing to see the patient (eg, 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)”

The guidelines also provide direction on which activities do not count toward time spent with the patient:

• Performing other separately reported services
• Travel
• General teaching that isn’t limited to discussing the specific patient’s management

Count Time Correctly

Distinct time is the amount of time each provider spends working on the patient independently. However, if both the physician and the APP are seeing the patient simultaneously, then only one of them can count the time. Typically, the physician will count the time, so the visit can be billed at the higher physician rate.

Remember: “You can’t double count that time. What I usually tell my providers is you need to document and use the word ‘distinct’ and make sure that you’re documenting what your distinct time is,” said Christopher Chandler, MHA, MBA, CPC, CGSC, technical manager of coding and reimbursement for lntermountain Health during his “Don’t Gamble on Incorrectly Billing for Advanced Practice Provider Services” session at AAPC’s HEALTHCON 2024.

Choose Billing Option Carefully

Sometimes, one provider will end up spending more time overall performing services with the patient, which can sway the time percentage significantly toward one provider over another. The other provider may not like this unequal distinct time split.

“The thing that I’ve heard from some physicians is that they don’t like the definition of distinct time as spending greater than 50 percent of the time with the patient,” Chandler said. The physicians may feel upset because the APP could spend more than half the time performing tasks and then get to bill under their NPI.

However, thinking that only face-to-face time counts toward determining time spent on the patient is a common misconception about basing the billing provider on time spent providing services. Chapter 12 section 30.6.18.B(3), the Medicare Claims Processing Manual states “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.”

“This means that if the physician can do [the tasks listed above] a lot faster and a lot more efficiently, the APP gets to bill for the encounter because they spend greater than 50 percent of the time performing the tasks,” Chandler continued.

He added that if the physician is concerned about the distinct time split, then they should consider basing the appropriate E/M on the substantive portion of MDM instead.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC