CMS Revises Split/Shared Services Definition for 2024

Editor’s note: AAOS partners with KarenZupko & Associates, Inc. (KZA) on the organization’s coding education, and KZA often provides content for AAOS Now. For more information, visit aaos.org/membership/coding-and-reimbursement.

“Split/shared billing” is a term developed and originally defined by the Centers for Medicare & Medicaid Services (CMS) for Medicare for reporting an Evaluation and Management (E/M) service in which both a physician and non-physician qualified healthcare professional (QHP) or advanced practice provider (APP) each provide a portion of service during a single visit in the facility setting. The purpose of this article is to clarify coding and billing for split/shared billing. If billed by the physician, reimbursement is at 100 percent of the Medicare Physician Fee Schedule (MPFS) allowable. If billed by the APP, reimbursement is 85 percent of the MPFS allowable; therefore, the payment is reduced by 15 percent.

Split/shared visits can be billed by either time (more than 50 percent of visit spent) or medical decision making (MDM) (substantiative portion). This distinction created confusion about how to document time versus a substantive portion. The amount of time or decision making required to meet the threshold for a substantiative portion performed by the physician was inconsistently presented in Medicare resources. In addition, for split/shared billing, there are no restrictions about the type of patient seen (new or established). However, split/shared reporting is only allowed in provider-based clinics (outpatient hospital place of service [POS] 19 or 22), facility services (POS 21, 22), and emergency room services (POS 23).

The American Medical Association used the term split/shared for the first time in the 2021 E/M guidelines but did not address Medicare (or other payer) rules for split/shared criteria. CMS revised its guidelines for split/shared reporting in 2022 and defined that the substantiative portion of the visit is provided by the professional who performed either the history, the examination, or the MDM in its entirety.

For 2024, Current Procedural Terminology (CPT) has revised the definition of split/shared visits, and CMS has finalized its policy reflecting the revised definition of the substantiative portion of a split (or shared) visit to reflect revisions to the CPT E/M guidelines. Standards for measuring the substantiative portion are different in 2024 than methods described in previous years.

Determining the substantive portion
The two options for determining the substantiative portion are outlined below.

Option 1 (Time): Report based on the professional who performs more than 50 percent of the face-to-face or non–face-to-face time of the service. If using option 1, the face-to-face or non–face-to-face time is on the day of the patient encounter. The following components count toward time and are consistent with those outlined in CPT 2024:

Preparing to see the patient
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 and communicating with other healthcare professionals (when not separately reported)
Documenting clinical information in the electronic or other health record
Independently interpreting results (not separately reported)
Communicating results to the patient/family/caregiver
Care coordination (not separately reported)

Option 2 (MDM): Report based on the professional who performs the substantive portion of MDM as defined in CPT 2024. In order to document substantive portion of MDM, the physician or QHP must do both of the following, according to CPT:

Make or approve the management plan for the number and complexity of problems addressed at the encounter
Take 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.

Please note: If using the amount and/or complexity of data to be reviewed and analyzed as one of the two elements needed for determining the level of visit, the independent interpretation of tests and the discussion of the management plan must be personally performed by the billing professional.

The good news for 2024 is that CPT and CMS are now aligned in their definitions for split/shared services. However, there are two key differences in utilization between CMS’s and CPT’s interpretations. CMS allows split/shared billing only in the facility setting (outpatient hospital, inpatient hospital, or emergency department), and CMS also requires modifier FS to be appended to identify the practitioner who provided the substantiative portion of the split/shared service. CPT does not define the sites of service or service types that may use this methodology, and it does not specify a modifier for use when billing for split/shared services. It is the physician’s responsibility to know whether CPT or CMS rules apply in his or her site of service. Clarification of the split/shared guidelines in 2024 were in hopes of simplifying guidelines for all payers.

KZA looks forward to welcoming AAOS members and other orthopaedic professionals at one of their national AAOS coding and reimbursement workshops in 2024. Learn more at kzanow.com.

Marissa Clemmer, CPC, CCS, CPMA, CPB, CANPC, CPEDC, is a consultant with KZA and is an instructor at the AAOS reimbursement and coding workshops.

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