Pulmonology Coding Alert

“Split/shared billing refers to evaluation and management (E/M) services rendered in a facility setting that are shared by both a physician and a nonphysician practitioner [NPP] who can bill an E/M service,” said Maryann C. Palmeter, CPC, CPCO, CPMA, CENTC, CHC, director of physician billing compliance at University of Florida Jacksonville Healthcare Inc. during the AAPC HEALTHCON 2022 conference session “Don’t Be Scared of Shared (Billing).”

In Calendar Year (CY) 2022, physicians and advanced practice professionals (APPs) may split or share billing for E/M services provided in eligible facility settings. An APP, sometimes called an NPP, is a qualified individual who may be supervised by a physician or who collaborates with a physician to provide care to a patient.

Medicare recognizes the following APPs as being able to report E/M services:

• Certified nurse midwife (CNM)
• Clinical nurse specialist (CNS)
• Nurse practitioner (NP)
• Physician assistant (PA)

Split/shared billing only applies to E/M services, not procedures, for new and established patients during initial and subsequent encounters. In 2022, either the physician or APP may bill split/shared under their provider number depending on who performs the substantive portion of the visit, defined by one of the following methods:

• History, or exam, or medical decision making (MDM) performed in its entirety; or
• More than half of the total time spent performing the visit.

o Note: Time-based services (e.g., critical care) are required to use the time-based method to determine substantive portion.

However, CMS is changing the way the substantive portion is determined after the new year.

Look Ahead to 2023 Policy Update

CMS has announced billing policy updates for split/shared visits that take effect when the calendar flips on Jan. 1, 2023. In the updated policy, CMS will exclusively define the substantive portion of split/shared visits as more than half the total time performing the visit — instead of allowing the component-based option (history, or physical exam, or MDM).

This change, along with changes “the AMA is planning … to the inpatient E/M, observation E/M, and emergency room code sets in 2023 … will likely have an impact on split/shared billing. At least, it appears that CMS anticipated this when they came up with the split/shared billing guidelines, and by addressing 2023, even though it was the CY 2022 Final Rule,” Palmeter says.

For added clarity, examine the following scenario using 2022 and 2023 split/shared billing policies.

Scenario: A new patient visits a pulmonology clinic for an E/M visit for an asthma flare requiring adjustment of medications. An APP first spends 20 minutes with the patient capturing the patient’s history and performing a physical exam. Next, the physician spends another 15 minutes with the patient performing the substantive component of MDM. The time spent with the patient is summed to a total of 35 minutes.

Billing under the 2022 policy: Under the 2022 policy, the physician could submit the bill under their name for the visit since the substantive portion was determined and performed by the physician, in this case the substantive portion was MDM. To bill for the split/shared visit, the physician would select the visit level using either MDM or time, whichever is more beneficial. The visit level is not required to be selected by time for shared visits. If time is used to select the visit level, 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.) would be appropriate. If MDM is used, 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.) would be appropriate.

Billing under the 2023 policy: Since the 2023 policy uses time spent with the patient as the sole determining factor as to who may bill for the visit, the APP would submit the split/shared visit under their provider number under the new policy as they spent more time with the patient. The visit level, however, would be selected based on MDM or time, as above. Please note that the “substantive portion” only determines who can bill for the service. The CPT^® and payer guidelines determine the visit level.

Modifier note: Effective Jan. 1, 2022, modifier FS (Split (or shared) evaluation and management visit) must be appended to the appropriate E/M code to ensure correct reporting of shared visits. This is a Medicare-created modifier that other payers may not recognize.

Reaction to 2023 Split/Shared Billing Policy Changes

Several medical organizations are urging CMS Administrator Chiquita Brooks-LaSure to rescind the new bill that would allow time to become the only defining factor of the substantive portion of split/shared billing in 2023.

“While this policy has immense implications for physician and advanced practitioner reimbursement plans, our foremost concern lies with the detrimental impact on the care delivery model and the patient experience. Therefore, the undersigned organizations strongly urge CMS to discontinue its split/shared visits policy and not move forward with the transition set to take effect in 2023,” wrote the American College of Physicians (ACP) and signed in support by the American College of Chest Physicians (CHEST) in a letter to CMS on March 22, 2022 (www.chestnet.org/Newsroom/CHEST-News/2022/04/CMS-urged-to-rescind-APP-split-shared-policy).

In the letter, the organizations state they believe that CMS’ policies about split/shared visits could detract from delivering “effective co-management and clinical alignment” for care delivery. The organizations also cited other reasons for their concerns, which include the following:

• Pitting physicians and advanced practitioners against each other
• Potential negative impact on the patient experience
• Causing burnout for physicians and other practitioners
• Inadequate time to educate members on the transition to the new policy and its effects

With the Proposed Rule’s release on the horizon, stakeholders will be interested to see if CMS makes additional changes to the policy.