Wiki Split / Shared Inpatient E/M visits

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lmcreynolds@aoamail.net

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I am curious about how to bill split/shared inpatient E/M visits for Medicare patients. We have midlevel providers on call who, in the past, saw the patient and dictated the inpatient consult. The doctor would then exam the patient and attest the inpatient consult. The doctor would get the consult. In 2022, that changed to the charge going to whomever provided the substantive portion of the visit or one of the key components.

But now in 2023, if I understand correctly, it is just based on time? Is it whomever spends over 50% of the visit, is allowed the charge? And we still modifier FS to the E/M? And do you have your providers dictate the time in the consult note?

Is anyone else struggling with this? Any insight or opinions or advice would be greatly appreciated. Thank you.
 
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it looks like CMS changed it's mind, but I cannot tell if it has been set in stone.

per this AAPC article (emphasis added by me):

"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.”"
 
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There is reference to 2023 here:
30.6.18 - Split (or Shared) Visits

Not sure if that is still the case though:

Split (or Shared) E/M Visits

For CY 2023, we finalized a year-long delay of the split (or shared) visits policy we established in rulemaking for 2022. This policy determines which professional should bill for a shared visit by defining the “substantive portion,” of the service as more than half of the total time. Therefore, for CY 2023, as in CY 2022, the substantive portion of a visit is comprised of any of the following elements:
  • History.
  • Performing a physical exam.
  • Medical Decision Making.
  • Spending time (more than half of the total time spent by the practitioner who bills the visit).
As finalized, clinicians who furnish split (or shared) visits will continue to have a choice of history, or 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, until CY 2024.

 
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Hi there,

Medicare announced in the 2023 final physician fee schedule that you can continue to use a key component (history, exam or MDM) to determine substantiate portion until 2024. Discussion of the final split (or shared) rule begins on p. 591 of the rule. (This link may stop working later in 2023, go to this page if it does).

Medicare's final comment:

After considering the public comments we received, we are finalizing our proposed policy to delay implementation of our definition of the substantive portion as more than half of the total practitioner time until January 1, 2024.
Click to expand...

From a PBN blog post on the final rule

Component-based split (or shared) services spared. CMS will delay the requirement that practices use time to determine who performed the substantive portion of a visit under its split/shared rule until Jan. 1, 2024. CMS listened to feedback from the medical community and will allow practices to determine the substantive portion of a visit for all level-based codes except emergency department visits with total time or performance of history, physical exam or medical decision making through 2023.
Click to expand...

In my opinion the big problem is that Medicare hasn't said what sort of documentation will support the substantive portion of history or physical exam. Maybe the MACs will step in, but proceed with caution if you don't use MDM.

If you use time both providers must document their total time in some way.

Append modifier FS to all Medicare split/shared visits.
 
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The CMS Calendar Year (CY) 2023 Medicare Physician Fee Schedule Final Rule can be found at: https://www.cms.gov/newsroom/fact-s...23-medicare-physician-fee-schedule-final-rule. It clearly indicated for split/share E/M visits the
"clinicians who furnish split (or shared) visits will continue to have a choice of history, or 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, until CY 2024."

So the glitch in my thinking is this split/share rule determines who will be the billing provider, but are we using the 2023 MDM grid to determine the billing level?
 
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Correct. By the CMS rules, you could use exam as the "substantive portion" but the exam will not be used in leveling the visit. 🤪
 
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Let me give an example to see if I understood correctly.
APP sees inpatient and does Hx, PE and provides an assessment. MD does the same. Let's say the substantive portion happens to be the PE done be the APP, so the billing provider is the APP. However, the visit level is determined by the 2023 MDM of either the APP or MD (whichever is higher). So in essence, we are using two sets of rules when dealing with inpatient split/share .
 
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LauraNewYork said:
Let me give an example to see if I understood correctly.
APP sees inpatient and does Hx, PE and provides an assessment. MD does the same. Let's say the substantive portion happens to be the PE done be the APP, so the billing provider is the APP. However, the visit level is determined by the 2023 MDM of either the APP or MD (whichever is higher). So in essence, we are using two sets of rules when dealing with inpatient split/share .
Click to expand...
Hi there - Yes there are two sets of rules.

Under the CPT guidelines for split/shared coding you must use time-based coding as defined in the CPT guidelines. Please review those guidelines closely, including the activities that count toward time and how to count combined time.
 
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LauraNewYork said:
Please note: The time based coding was delayed until 2024.
Click to expand...
That's for billing a visit under the CMS split/shared rule. Practices have the option to use time or a component (physical, exam or MDM) to determine who performed the substantive portion until 2024. And CMS may push the date back again. :)

Time is the only option for coding (selecting the visit level) under CPT split/shared guidelines.
 
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