by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Feb 24th, 2022
In the 2021 Medicare Final Rule, changes to the reporting guidelines for split or shared services were made, effective on January 1, 2022 with additional changes effective January 1, 2023. Many organizations struggle to understand reporting split or shared services but these changes claim to clear up any misunderstandings and align more with the CPT guidelines.
Historically, the concept of split or shared services was a Centers for Medicare and Medicaid (CMS) concept, which allowed physicians and nonphysician practitioners (NPPs) also referred to as qualified healthcare practitioners (QHP) by the AMA to split or share in performing and documenting the E/M service, and bill for those services under the physician’s provider number. Only a handful of commercial payers have followed Medicare’s guidelines and adopted split or shared service reimbursement policies.
In 2021, the American Medical Association (AMA) revised the E/M guidelines for codes 99202-99215 and added terminology supporting split or shared services as follows:
| “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.” |
In a split or shared service, a physician and NPP/QHP each provide a face-to-face encounter with the patient, at different times but on the same day. If both providers see the patient together, it does not qualify as a split or shared service and if the E/M service is scored based on time, only the time of one of the providers may be used for scoring the level of service.
Split or Shared Service Reporting Changes from 2021-2023
When performing split or shared services in 2021, each provider was responsible for documenting the key component(s) of the E/M service they performed. If the encounter was to be scored based on time, the provider would document face-to-face (F2F), non-face-to-face (NF2F), or a combination of the two (F2F/NF2F) along with a summary describing how that time was spent. Both provider notes were combined for E/M scoring and so were their times.
As of 2021, E/M services (99202-99215) allow providers to count F2F time and time spent performing eligible, NF2F services towards their total E/M encounter time. All other E/M service categories only count F2F time and only when time spent counseling and coordinating care dominated more than 50% the E/M service. However, all time-based services require documentation of the total time as well as a summary of how that time was spent as part of the medical record.
For 99202-99215, according to the new 2021 E/M guidelines, providers performing split or shared services document the component(s) of E/M they performed as well as the total time spent performing F2F and eligible /NF2F services. For E/M codes other than 99202-99215, the documentation of both providers was combined and scored to determine the level of E/M to be reported, either by time or components. If the providers spent time together with the patient, only the time of one of the providers could be counted towards the total time. For both E/M types the split or shared service was reported under the provider number of the physician and processed for payment at 100% of Medicare allowable.
In 2022, Medicare published changes for split or shared service reporting no longer allow these services to automatically be billed under the physician’s NPI. Instead, whichever provider performed the substantive portion of the split or shared service will report the service under their provider number, bringing a potential savings for payers and loss to provider of 15% if these services end up billed under the NPP/QHPs provider number. Identifying the substantive portion becomes tricky when you consider the scoring requirements for 99202-99215 compared to all other E/M services.
Split or shared services requires both providers separately perform and document the E/M component(s) and time spent performing F2F/NF2F services. Then the documentation is combined to determine the overall level of E/M service to be reported and which provider performed and documented the substantive portion of the service, whether by time or by components.
Scenario: Patient Sally Doe, was seen today in a split or shared service by NP Judy and Dr. Smith. NP Judy performed and documented a history and examination, spending a total of 25 minutes F2F with the patient. Dr. Smith spent 5 minutes reviewing NP Judy’s notes and then met with the patient where he asked a few more questions about her history and then performed and documented the MDM portion of the service. Dr. Smith spent a total of 20 minutes F2F/NF2F. Which provider performed the substantive portion?
If we were scoring this based on the 99202-99215 codes, the physician would have performed the substantive portion because component scoring for these codes is based on MDM alone, as history and exam are not part of the scoring process, and the MDM was documented by Dr. Smith. If the scoring was based on one of the other E/M service codes, which require documentation and scoring of three key components, the substantive portion would have been provided by NP Judy, as she documented both the history and examination or the substantive portion.
If scored based on time, NP Judy would have provided the substantive portion at 25 minutes over Dr. Smith’s 20 minutes. Although the service would be billed under NP Judy’s provider number and reimbursed at 85% of the fee schedule, both provider encounter times are still added together to determine the E/M level of service to be reported at 45 minutes (99215).
In 2023, the next change applied to split or shared services by Medicare will be a change from determining who performed the substantive portion to who the documentation reflects spent the most time with the patient.
This 2023 change will require all providers performing split or shared services to always document their time.
What is the Substantive Portion of an E/M Encounter?
To review, in 2022 the provider who performed and documented the substantive portion of a split or shared E/M service bills under their provider number and in 2023, the provider who spent the most documented time will bill under their provider number. The level of service is still determined by combining the times of both providers but who the claim is billed under is determined by who spent the most documented time with the patient.
Locations Eligible for Reporting Split or Shared Services
The following locations are eligible for reporting split or shared services in 2022 and are identified by their place of service (POS) codes:
- Outpatient facility (on/off campus) (POS 19, 22)
- Hospital facilities
- Inpatient facility (POS 21)
- Observation (POS 22)
- Emergency Department (POS 23)
- Skilled Nursing Facilities/Nursing Facilities (POS 30, 31) with special requirements such as certain mandated E/M services that must be performed by a physician are not eligible for split or shared service reporting.
- Critical Care Services (adhering to special circumstances)
NOTE: POS 11 is not eligible for reporting split or shared services but is an eligible location for incident to service reporting when the documentation supports it. For additional information on reporting incident-to services CLICK HERE.
New Modifier For Reporting Split or Shared Services
Effective January 1, 2022, modifier FS (split or shared E/M visit) is required on all split/shared services reported for Medicare beneficiaries. Please review updated policies for individual payers to identify whether they too will require the FS modifier for reporting purposes.
CLICK HERE to register for a complimentary webinar covering the new split or shared services coding guidelines sprinkled with a hint of incident to service reporting.
| Disclaimer: The above article is the opinion of the author(s) and should not be interpreted by providers/payers as official guidance. For any questions about the content of this article, please contact the author(s). |
About the Author: Aimee 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. She 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.
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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