Definition

“Physician(s) and other qualified healthcare professional(s) may act as a team in providing care for the patient, working together during a single E/M service.”

“E/M services furnished in a facility setting ... ” “a split or shared visit refers to an E/M visit performed by both a physician and an NPP in the same group practice.”

“In the non-facility (for example, office) setting, the rules for ‘incident to’ billing apply under this circumstance.” p. 468

Same group, same specialty. See location below.

CMS adopting CPT® definitions

“However, given these recent changes in the CPT guidelines for split (or shared) visits and our interest in reducing coding and billing administrative burden on health professionals to continue to alignment with revised overarching guidelines for E/M visits, we are reconsidering our policy for defining ‘substantive portion’ as it applies to split or shared visits.” p. 475

Continuing to allow time or MDM for 2024. “Delaying” implementation of time only, for the third year in a row. Took out “one of the three key components” since neither history nor exam are used to select a level of service.

Location

CPT doesn’t mention location (facility, non­facility settings)

Facility settings only

Use split/shared only in a facility setting for Medicare patients. For Medicare patients in the office, if the service meets incident to guidelines, may bill under the physician. If it doesn’t meet incident to guidelines, bill under the NPP. For commercial insurances—unknown.

Substantive portion based on time

“If the code selection is based on total time on the date of the encounter, the service is reported by the professional spent the majority of the face-to-face or non-face-to-face time performing the service.” p. 6 CPT

“Specifically, for CY 2024, for purposes of Medicare billing for split or shared services, the definition of ‘substantive portion’ continues to mean more than half of the total time by the physician and NPP performing the split or shared visit.” p. 476

However, CMS is allowing time or MDM; not requiring time be used to determine the substantive portion.

Substantive portion based on number and complexity of problems

“ ... performance of a substantive part of the MDM requires that the physician(s) or other QHP(s) made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management. By doing so, a physician or other QHP has performed two of the three elements used in the selection of the code level based on MDM. If the code selection is based on total time on the date of the encounter, the service is reported by the professional spent the majority of the face-to-face or non-face-to-face time performing the service.” p. 6 CPT

“Although we continue to believe there can be instances where MDM is not easily attributed to a single physician or NPP when the work is shared, we expect that whoever performs the MDM and subsequently bills the visit would appropriately document the MDM in the medical record to support the billing of the visit.” p. 475

Per CPT: practitioner can use any two of the three MDM elements. CPT says “made or approved” and “takes responsibility.” Physician or NPP “has performed.” Silent on what needs to be documented by the billing practitioner.

What CPT® says about data

“If the amount and/or complexity of data to be reviewed and analyzed is used by the physician or other QHP to determine the reported code level, assessing an independent historian’s narrative and the ordering or review of tests or documents do not have to be personally performed by the physician or other QHP, because the relevant items would be considered in formulating the management plan. Independent interpretation of tests and discussion of management plan or test interpretation must be personally performed by the physician or other QHP if these are used to determine the reported code level by the physician or other QHP.” “ ... performance of a substantive part of the MDM requires that the physician(s) or other QHP(s) made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management. By doing so, a physician or other QHP has performed two of the three elements used in the selection of the code level based on MDM.” “If the code selection is based on total time on the date of the encounter, the service is reported by the professional spent the majority of the face-to-face or non-face-to-face time performing the service.” p. 6 CPT

CMS doesn’t comment on the individual elements of the MDM in determining the substantive portion, but quotes CPT in the Final Rule.

If using data to select the level of service. Ordering and reviewing tests or documents or using an independent historian do not have to be personally performed by billing provider. An independent interpretation and discussion of management plan/test interpretation must be done by billing provider (if data is an element used to determine the level of code reported).

Documentation

Quote from above ... “made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan...”

From above statement “...whoever performs the MDM and subsequently bills the visit would appropriately document the MDM in the medical record...” p.475

CHECK YOUR MAC: NGS: “In order to bill the service as the ‘substantive’ provider, the physician’s documentation would need to describe the physician’s work as exceeding the NPP’s work in completing the service. In either reviewing the NPP’s history and/or exam findings and in formulation a medical decision, the physician’s performance and documentation would need to exceed the NPP’s efforts and documentation of the split/shared service.”

https://www.ngsmedicare.com/ja/evaluation-and-management?lob+96664&state=97224&origin=93623&selectedArticleId=330568.

CPT seems to allow an attestation statement when MDM is based on number of problems and risk.

CMS says “would appropriately document.”

Check your MAC. For Medicare, I recommend not using attestation statements unless your MAC specifically allows it.