Practice Management Alert

Understanding ‘substantive portion’ is key to billing some E/M services correctly.

Beginning in 2022, many who work in medical billing with physicians engaged in hospital-based inpatient or hospital-based outpatient or emergency department settings are currently navigating how to bill split and shared visits to Medicare.

“If you’ve got two providers, one MD or DO, and one midlevel provider, like an [nonphysician practitioner] NPP, if they share in a visit with an MD or DO, then it’s considered one visit. But how do you split up that visit? How do you determine who gets credit?” says Terry A. Fletcher, BS, CPC, CCS-P, CCS, CEMC, CCC, CMSCS, CMC, of Terry Fletcher Consulting Inc., in Laguna Beach, California. Remember, office visits are not billable as split or shared visits. “For Medicare, what the CPT^® book says now, remember, you can’t use that, as far as the 99202-99205, 99212-99215, because that’s been changed.”

Here’s some context and definitions to help you better understand some answers to common questions, on page 1.

Know These Terms

Context: Beginning in 2022, the new definition of a split or shared visit is “an evaluation and management (E/M) visit in a facility setting that is performed in part by a physician and an NPP who are in the same group, in accordance with applicable law and regulation, such that the service could be billed by either the physician or the NPP if performed by only one. You have to be able to bill Medicare in this split or shared visit. Payment is made to the practitioner who performs the substantive portion of the visit,” according to the Centers for Medicare & Medicaid Services (CMS)’ 2022 Final Rule.

“The split/shared billing concept is applicable to new and established patients, as well as initial and subsequent encounters,” said Maryann Palmeter, CPC, CPCO, CPMA, CENTC, CHC, during a session on Shared Billing at AAPC’s HEALTHCON 2022.

APP: Advanced practice provider. An individual qualified by education, training, licensure/regulation, and facility privileging who performs a professional service within their state scope of practice and may independently report that professional service. APPs may be supervised by a physician or collaborate with a physician. Medicare recognizes the following as APPs: certified nurse midwife, clinical nurse specialist, nurse practitioner, physician assistant.

Distinct time: Time spent separately on patient care by the physician or APP

Facility setting: Institutional settings in which payment for professional services and supplies furnished incident-to a physician or practitioner’s professional services is prohibited and Medicare benefits are assigned to the patient. Note, physician offices (Place of Service [POS] code 11), urgent care center (POS code 20), and nursing facilities (POS 32) are not considered facility settings.

Joint time: Time spent by the physician/APP discussing/assessing the patient together. Note: Joint physician/APP time may be added to arrive at the time reported, but when physicians and APPs jointly meet with or discuss the patient, only the time of one of the practitioners may be counted.

Key component: History, physical examination, and medical decision making portions of an E/M service.

MDM: Medical decision making

NPP: Nonphysician practitioners

Qualifying time: From the CPT^® guidelines for E/M services, the activities that can be counted toward total time for purposes of determining the substantive portion, including activities involving direct or indirect patient care. Note that none of the following can be counted: performance of other services reported separately, travel, or general teaching that is not limited to discussion required for management of a specific patient.

QHP: Qualified healthcare professional

Substantive portion: The part of an E/M service that involves all of the history, the exam, or the MDM components OR more than half of the total time spent by the physician and APP performing the split (or shared) visit.