by Wyn Staheli, Director of Content - innoviHealth
and Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Jun 16th, 2021
As you may be well aware, a split or shared E/M encounter refers to a face-to-face E/M encounter where an encounter is performed by both a nonphysician practitioner (NPP) (e.g., midlevel, QHP, NP, PA, CNS) and a physician. Reporting of split (or shared) services has always been wrought with the potential for incorrect reporting when the fundamental principles of the service are not understood. A recent CMS publication about these services further complicates the matter.
The basic principle to be followed is that each provider’s contribution is individually documented and scored and the sum of both is used to determine the overall E/M level. If reporting is based on time, then time spent by each provider is added together to determine the total time for code selection with one caveat, which is that when MD and QHP/NPP have overlapping time with the patient (they are in the room together), only the time spent together for one provider may be used in the calculation. For reporting purposes, the service is eligible to be reported under the NPI of either the physician or the NPP, but not both.
That seems straightforward enough, but there’s a new twist to the plot. It should be noted that prior to 2021, the CPT codebook did not include guidance on split/shared services even though CMS did (see “CMS and Split/Shared” below). As of January 2021, the CPT codebook includes the following definition as part of the guidelines for all E/M services, not just Office or Other Outpatient Services (emphasis added):
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A shared or split visit is defined as a visit in which a physician and other qualified health care professional(s) jointly provide the face-to-face and non-face-to-face work related to the visit. When time is being used to select the appropriate level of services for which time-based reporting of shared or split visits is allowed, the time personally spent by the physician and other qualified health care professional(s) assessing and managing the patient on the date of the encounter is summed to define total time. Only distinct time should be summed for shared or split visits (ie, when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted). |
Tip: For more information about qualified healthcare professionals, CLICK HERE.
CMS and Split/Shared Services
The addition of this new definition in the CPT codebook necessitated a review of the Medicare Claims Processing Manual (also known as Pub-100-04) in relation to these types of encounters. As such, major changes to the guidelines have been removed due to a recent petition which challenged certain sections. Consequently, the following sections relating to the coding of split (or shared) encounters were removed:
- 30.6.1 Selection of Level of Evaluation and Management Service, B. Selection of Level of Evaluation and Management Service; Split/Shared E/M Service
- 30.6.12 Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292), Critical Care Services (Codes 99291-99292)
- Nursing Facility Services, H. Split/Shared E/M Visit
The removal of these sections requires coders to look elsewhere for guidance until CMS can properly and legally address these topics and provide new guidelines through the notice-and-comment rulemaking process. In the meantime, from May 26, 2021 through the end of 2021, when reporting split or shared services, refer to the remaining viable sources such as the Social Security Act and U.S. Code of Federal Regulations, and others.
Even though these sections are removed, the notice states the following about requirements that are still in effect:
- “Incident to” information as found in certain sections of the Social Security Act (e.g., 1861(s)(1), 1861(s)(2)(A)) and 42 C.F.R (e.g., 410.20, 410.74)
- Payment reductions as found in certain sections of the Social Security Act (e.g., 1833(a)(1)(N), 1861(s)(2)(K)) and 42 C.F.R (e.g., 410.26)
- Code set requirements to follow HIPAA (e.g., CPT, HCPCS)
- General adoption of new Office or Other Outpatient E/M Services (99202-99215) codes and “interpretive guidance” issued by the CPT Editorial Panel
Note that “incident to” rules still apply so be careful that non-physician practitioners (NPP) only report those services if there is NO new condition or change in the course of treatment. If the patient presents with a new problem, the patient will either need to be seen by the physician for incident to rules to be met or the service should be billed under the QHP’s National Provider Identification (NPI).
Tip: Detailed information on “incident to” services is found in the Evaluation and Management Comprehensive Guide publication, available in the online store.
On a positive note, until CMS publishes a final rule regarding split/shared services, they stated that they will be limiting reviews of claims for these types of services. However, it doesn’t say they will stop them, just limit them, so be sure that joint encounters are properly documented.
References/Resources
About Wyn Staheli, Director of Content - innoviHealth
Wyn Staheli is the Director of Content Research for innovHealth. She has over 30 years of experience in the healthcare industry. With her degree in Management Information Systems (MIS), she has been a programmer for a large insurance carrier as well as a California hospital system. She is also the author and editor of many medical resource books and the founder of InstaCode Institute.
About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.
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