2022 – A Transitional Year for Changes to Split/Shared Visit Guidelines

Written by: AIHC Blogger

This article provides general guidance related to 2022 and 2023 changes made to split/shared visit guidelines as outlined in the Medicare Claims Processing Manual 100-04, Chapter 12. Please reference payor and Medicare guidelines for complete information. This article is not intended as coding, consulting or legal advice, but to summarize highlights of the important changes to the documentation, coding and billing of these services.

What Is the Definition of a Split (or Shared) Visit?

According to Medicare, a split (or shared) visit, also referred to as “split/shared” visit, is an evaluation and management (E/M) visit in the facility setting* that is performed in part by both a physician and a nonphysician practitioner (NPP) who are in the same group, in accordance with applicable law and regulations such that the service could be billed by either the physician or NPP (practitioner) if furnished independently by only one of them.

*Facility setting means an institutional setting, such as the hospital, where the hospital is reimbursed for services and supplies furnished incident to a physician or practitioner’s professional services as these items are not at the practitioner’s expense.

Don’t Confuse Office “Incident-to” With Split/Shared Visits

Services performed by non-physician practitioners (NPPs) incident to a physician’s professional services include not only services ordinarily rendered by a physician’s office staff person (e.g., medical services such as taking blood pressures and temperatures, giving injections, and changing dressings) but also services ordinarily performed by the physician such as minor surgery, setting casts or simple fractures, reading x-rays, and other activities that involve evaluation or treatment of a patient’s condition.

Hospital and skilled nursing facility services cannot be billed as "incident-to" at any time.

In order for services of a NPP to be covered as incident-to the services of a physician (and paid at 100% of the fee schedule instead of 85%), the services must meet all of the requirements for coverage specified in Medicare’s policy manual (§§60 through 60.1). For example, the services must be an integral, although incidental, part of the physician’s personal professional services, and they must be performed under the physician’s direct supervision.

The Medicare Benefit Policy Manual, 100-02, Chapter 15, Section 60 is a great resource to reference as well as your Medicare Administrative Contractor (MAC) for more guidance and tools for compliant incident-to billing.

Payment is made to the practitioner who performs the substantive portion of the visit. So, what does that mean?

“Substantive portion” means more than half of the total time as of January 1, 2023. In 2022, we are in a transitional period.

During the transitional year, from January 1, 2022, through December 31, 2022, (with the exception of critical care visits) the substantive portion can be one of the three key E/M visit components. Remember, 1995 and/or 1997 documentation guidelines apply to E/M other than the physician office visits:

• History;
• Exam; or
• Medical decision-making (MDM)); or
• More than half of the total time spent by the physician and NPP performing the split (or shared) visit.

In other words, for calendar year 2022, the practitioner who spends more than half of the total time, or performs the history, exam, or MDM can be considered to have performed the substantive portion and can bill for the split (or shared) E/M visit.

When one of the three key components is used as the substantive portion in 2022, the practitioner who bills the visit must perform that component in its entirety in order to bill.

Let’s look at an example: 

• If the history documentation is used as the substantive portion and both practitioners take part of the history, the billing practitioner must perform the level of history required to select the visit level billed.
• When the physical exam is used as the substantive portion and both practitioners examine the patient, the billing practitioner must perform the level of exam required to select the visit level billed.
• When the MDM element is used as the substantive portion, each practitioner could perform certain aspects of MDM, but the billing practitioner must perform all portions or aspects of MDM that are required to select the visit level billed.

Distinct & Qualifying Time

Distinct Time - only distinct time can be counted. When the practitioners jointly meet with or discuss the patient, only the time of one of the practitioners can be counted.

Example: If the NPP first spent 10 minutes with the patient and the physician then spends another 15 minutes, their individual time spent would be summed (10 + 15) to equal a total of 25 minutes.

• The physician would bill for this visit, since they spent more than half of the total time (15 of 25 total minutes).

Now, if, in the same situation, the physician and non-physician practitioner (NPP) met together for five additional minutes (beyond the 25 minutes) to discuss the patient’s treatment plan, that overlapping time could only be counted once for purposes of establishing total time and who provided the substantive portion of the visit.

• The total time would be 30 minutes.
• The physician would bill for the visit, since they spent more than half of the total time (20 of 30 total minutes).

Qualifying Time - Drawing on the CPT E/M Guidelines, except for critical care visits, the following list of activities can be counted toward total time for purposes of determining the substantive portion when performed, and whether or not the activities involve direct patient contact:

• Preparing to see the patient (for example, review of tests);
• Obtaining and/or reviewing separately obtained history;
• Performing a medically appropriate examination and/or evaluation;
• Counseling and educating the patient/family/caregiver;
• Ordering medications, tests, or procedures.;
• Referring or communicating with other health care professionals (when not separately reported);
• Documenting clinical information in the electronic or other health record;
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver; and
• Care coordination (not separately reported).

Practitioners cannot count time spent on the following:

• The performance of other services that are reported separately;
• Travel;
• Teaching that is general and not limited to discussion that is required for the management of a specific patient.

For critical care visits, starting for services furnished in CY 2022, the substantive portion will be more than half of the total time. A unique listing of qualifying activities for purposes of determining the substantive portion of critical care visits applies as compared to other E/M visits or services:

Prolonged Services for Split/Shared Visits

During the transitional calendar year 2022, when practitioners use a key component as the substantive portion, there will need to be a different approach for hospital outpatient E/M visits than other kinds of E/M visits:

• Outpatient - For shared hospital outpatient visits where practitioners use a key component as the substantive portion, prolonged services can be reported by the practitioner who reports the primary service, when the combined time of both practitioners meets the threshold for reporting prolonged hospital outpatient services (HCPCS code G2212).
• Other - For all other types of E/M visits (except emergency department and critical care visits), prolonged services can be reported by the practitioner who reports the primary service, when the combined time of both practitioners meets the threshold for reporting prolonged E/M services other than office/outpatient E/M visits (60 or more minutes beyond the typical time in the CPT code descriptor of the primary service). Note, emergency department and critical care visits are not reported as prolonged services.

Reporting Prolonged Services for Split (or Shared) Visits

Modifier -FS (Split or Shared E/M Visit) must be reported on claims for split/shared visits, to identify that the service was a split (or shared) visit.

• FS          Split (or shared) evaluation and management visit

Documentation in the medical record must identify the physician and NPP who performed the visit. The individual who performed the substantive portion of the visit (and therefore bills for the visit) must sign and date the medical record.

Critical Care and Medical Record Documentation

Critical care is a time-based service, as demonstrated in the code descriptions below:

What hasn’t changed is when management of a patient located in an intensive care unit does not meet the level of critical care. Those visits are reported using an inpatient hospital care service with CPT Subsequent Hospital Care using a code from CPT code range 99231 - 99233. Remember, you can’t report critical care codes 99291 and 99292 just because the patient is in Intensive Care. Also, remember that both Initial Hospital Care (CPT codes 99221 - 99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice. 

What is the definition of “Critical Care” then?

The American Medical Association (AMA) CPT guidelines indicate that critical care is the direct delivery by a physician(s) or other qualified healthcare professional (QHP) of medical care for a critically ill/injured patient in which there is acute impairment of one or more vital organ systems, such that there is a probability of imminent or life-threatening deterioration of the patient’s condition. It involves high complexity decision-making to treat single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.

Critical care requires the full attention of the physician or NPP and therefore, for any given time period spent providing critical care services, the practitioner cannot provide services to any other patient during the same period of time. Critical care time does not have to be continuous. Time can be aggregated, but time must be documented in the medical record.

According to Section 30.6.12.8 of the Medicare Claims Processing Manual, Chapter 12, practitioners must document in the medical record the total time (not necessarily start and stop times) that critical care services are furnished by each reporting practitioner.

• Documentation needs to indicate that the services furnished to the patient, including any concurrent care by the practitioners, are medically reasonable and necessary for the diagnosis and/or treatment of illness and/or injury or to improve the functioning of a malformed body member.

Split/Shared Critical Care

When critical care services are furnished as a split/shared visit, the substantive portion is defined as more than half the cumulative total time in qualifying activities that are included in CPT codes 99291 and 99292.

To bill split/shared critical care services, the billing practitioner first reports CPT code 99291 and, if 75 or more cumulative total minutes are spent providing critical care, the billing practitioner reports one or more units of CPT code 99292.

• Modifier -FS (split or shared E/M visit) must be appended to the critical care CPT code(s) on the claim.
      o FS - Split (or shared) evaluation and management visit

The same documentation rules apply for split/shared critical care visits as for other types of split/shared E/M visits. Consistent with all split/shared visits, when two or more practitioners spend time jointly meeting with or discussing the patient as part of a critical care service, the time can be counted only once for purposes of reporting the split/shared critical care visit.

Auditing for Concurrent Critical Care

Concurrent care is when more than one physician renders services that are more extensive than consultative services during a period of time. The reasonable and necessary services of each physician furnishing concurrent care is covered when each plays an active role in the patient’s treatment. In the context of critical care services, a critically ill patient may have more than one medical condition requiring diverse, specialized medical services and requiring more than one practitioner, each having a different specialty, playing an active role in the patient’s treatment. This is reflected through the practitioner’s taxonomy code when the claim is filed.

However, there are guidelines for concurrent care of practitioners in the same group or specialty:

• Physician(s) or NPP(s) in the same specialty and in the same group may provide concurrent follow-up care, such as a critical care visit subsequent to another practitioner’s critical care visit.
• This may be as part of continuous staff coverage or follow-up care to critical care services furnished earlier in the day on the same calendar date. In the situation where a practitioner furnishes the initial critical care service in its entirety and reports CPT code 99291, any additional practitioner(s) in the same specialty and the same group furnishing care concurrently to the same patient on the same date report their time using the code for subsequent time intervals (CPT code 99292).
• CPT code 99291 will not be reported more than once for the same patient on the same date by these practitioners. This policy recognizes that multiple practitioners in the same specialty and the same group can maintain continuity of care by providing follow-up care for the same patient on a single date.
• When one practitioner begins furnishing the initial critical care service, but does not meet the time required to report CPT code 99291, another practitioner in the same specialty and group can continue to deliver critical care to the same patient on the same date.
• The total time spent by the practitioners is aggregated to meet the time requirement to bill CPT code 99291. Once the cumulative required critical care service time is met to report CPT code 99291, CPT code 99292 can only be reported by a practitioner in the same specialty and group when an additional 30 minutes of critical care services have been furnished to the same patient on the same date (74 minutes + 30 minutes = 104 total minutes).

Provide Sufficient Concurrent Care Documentation

To support coverage and payment determinations regarding concurrent care, services must be sufficiently documented to allow a medical reviewer to determine the role each practitioner played in the patient’s care (that is, the condition or conditions for which the practitioner treated the patient). When critical care services are reported the same date as another E/M visit, the medical record documentation must support:

1. The other E/M visit was provided prior to the critical care services at a time when the patient did not require critical care; 
2. The services were medically necessary; and  
3. Services were separate and distinct, with no duplicative elements from the critical care services provided later on that date.

When critical care services are furnished in conjunction with a global procedure, the medical record documentation must support that the critical care was unrelated to the procedure.

Additional Resources

• Medicare Claims Processing Manual 100-04, Chapter 12 - Physicians/Nonphysician Practitioners
• Short Course in Clinical Documentation Improvement – for Physician Services (pro fee filed on 1500 claim). This training is designed for Practitioners, Practice Administrators, Office Nurses, Coders, Professional Auditors and others tasked with the responsibility to improve documentation standards for medical practices.