Pulmonology Coding Alert

In the article, “Simplifying Who Can Bill Split/Shared Visits in 2023 May Cause More Headaches,” in Pulmonology Coding Alert, Volume 23, Issue 7, we looked at the changes facing split/shared visit billing in 2023. However, the Centers for Medicare & Medicaid Services (CMS) proposed a pause of the policy changes in the calendar year (CY) 2023 Medicare Physician Fee Schedule (PFS) proposed rule.

Learn what this proposed policy pause means for your practice.

Understand Who Can Bill for Split/Shared Visits

According to Medicare, split/shared billing occurs when a physician and a nonphysician practitioner (NPP) from the same group practice provide evaluation and management (E/M) services in a facility setting. In CY 2022, physicians and NPPs can split or share billing for E/M services provided in qualifying facility settings, such as inpatient hospitals, outpatient hospitals, emergency departments, and select nursing facilities.

Advanced practice professionals (APPs), occasionally referred to as NPPs, are qualified providers who may be supervised by physicians or collaborate with physicians to render care to patients.

Examples of APPs recognized by CMS who can report E/M services include:

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

Recap the Changes to Split/Shared Billing

In the CY 2022 PFS final rule, CMS finalized a phase-in approach to the split/shared billing policy. During the one-year transition period, Medicare finalized that the provider who performed the substantive portion of the visit could bill under their national provider identifier (NPI). The agency also finalized the definition of the substantive portion of an E/M visit, except for critical care visits, as:

• CY 2022: The provider (physician or APP) who performed the patient history, physical examination, or medical decision making (MDM) — or — the provider who spent more than half of the total time rendering the service
• CY 2023: The provider who spends more than half of the total time rendering the service

However, in the CY 2023 Medicare PFS proposed rule, CMS noted they received “continued concerns about the implementation of [the] phased-in approach.” Reasons include concerns about using only more than half of the total time to identify the substantive portion as well as requests to recognize MDM as the substantive portion.

Instead of requiring providers to use the substantive portion definition of “more than half of the total time” on Jan. 1, 2023, CMS is proposing to delay the policy implementation until CY 2024 after receiving feedback from stakeholders.

If the CY 2023 proposed rule is finalized, “Clinicians who furnish split (or shared) visits will continue to have a choice of history, physical exam, or medical decision making, or more than half of the total practitioner time spent to define the substantive portion, instead of using total time to determine the substantive portion.”

Why Did CMS Change Its Mind?

If Medicare finalized the policy in 2022, why did they reverse their decision? CMS lists two reasons in the CY 2023 PFS proposed rule to back up that choice.

1) 2023 E/M updates: Effective Jan. 1, 2023, several E/M codes will update to fall in line with the 2021 E/M changes to coding for office and other outpatient services. Examples of these codes include 99221-99223 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination …) and 99281-99285 (Emergency department visit for the evaluation and management of a patient …).

Delaying the split/shared visit policy implementation until 2024 gives providers a transition year to get acclimated to the 2023 E/M guidelines and get their practices up to speed on the incoming changes.

2) Feedback: The delay allows CMS to gather more comments and feedback from interested stakeholders regarding the policy and how it could be altered or further refined.

“I personally feel it’s more advantageous to the providers to have the substantive portion — and have it be either the MDM or the more than half the time — that is going to determine the code,” said Sandy Giangreco Brown, MHA, BS, RHIT, CHC, CCS, CCS-P, CPC, CPC-I, COBGC, COC, PCS, during the “Compliance Issues with Billing for Non-Physician Practitioners” session at AAPC’s HEALTHCON Regional 2022 conference.

In a March 2022 letter to CMS administrator Chiquita Brooks- LaSure, several medical organizations strongly urged “CMS to discontinue its split/shared visits policy and not move forward with the transition set to take effect in 2023.” The organizations felt the policy wouldn’t allow providers to effectively co-manage patients’ needs and was contrary to clinical alignment. Additionally, the organizations felt the policy “pits physicians and advanced practitioners against one another, which is incompatible with the intent of the care delivery model” (www.chestnet.org/Newsroom/CHEST-News/2022/04/CMS-urged-to-rescind-APP-split-shared-policy).

Note: Read the Pulmonology Coding Alert, Volume 23, Issue 7, article here: www.aapc.com/codes/coding-newsletters/my-pulmonology-coding-alert/billing-simplifying-who-can-bill-splitshared-visits-in-2023-may-cause-more-headaches-172458-article.