Correct Billing of Split (Shared) Services
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Correct Billing of Split (Shared) Services
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A split (shared) service is an evaluation and management (E/M) service where both the MD/DO and non-physician practitioner (NPP) work together to provide care to the patient. Correct billing requires:
- Medical necessity
- Documentation to support level of care
- Approved location
- Group practice
- Substantive portion identified
- Documentation to support billing provider
- Modifier FS
Medical Necessity
Treatment is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Social Security Act 1862(a)(1)(a)
Medicare does not need medical necessity documentation to support why services are performed as split/shared.
Level of Care
Choose the level of care (with exceptions) using either time or medical decision-making (MDM). Exceptions:
- Emergency room services – use MDM only
- Critical Care services – use time only
Use documentation from both providers to determine the level of care provided. Use the split (shared) guidelines to determine under which provider to submit charges.
Approved Location
Medicare allows a split (shared) service in a facility setting. Valid locations include a hospital or skilled nursing facility (SNF). A hospital setting includes:
- Inpatient
- Outpatient
- Emergency Room
- Observation
- Critical Care
A SNF is a Medicare-certified facility providing both room and board and skilled medical services to a patient. The SNF enrolls with Medicare.
Group Practice
Both the MD/DO and NPP must have Medicare enrollment. Both practitioners must be able to submit an E/M to Medicare under their National Provider Identifier (NPI). Do not use a non-enrolled practitioner’s documentation to meet the split (shared) guidelines.
CMS does not define “group practice” for a split (shared) service. CMS allows the MD/DO and NPP involved in the split (shared) care to determine if they are a group. An example shared with us is NPPs employed by the hospital splitting (sharing) services with a group of cardiologists. The two entities decide if they are a group. Practitioners must be able to show how they are a group with the other practitioner, should Medicare request information.
When entities are not part of the same TAX ID, payment arrangements are part of the group agreement. Medicare sends payment to the billing practitioner.
Substantive Portion
The practitioner providing the substantive portion of the service can submit the charge to Medicare. The level of care chosen includes services by both the MD/DO and NPP.
Choose the practitioner providing the substantive portion by either:
- Time (Use time only for services 01/01/2024 and after)
- E/M components (effective for dates of service 01/01/2022 through 12/31/2023)
- History
- Exam
- Medical Decision-Making (MDM)
Time
Bill under the practitioner who provided the most patient care time. This includes both face-to-face and non-face-to-face qualifying time. One practitioner must provide a face-to-face service. Non-face-to-face services may include the qualifying activities listed below.
Qualifying Time:
- Preparing to see the patient (i.e., review of tests)
- Obtaining and or reviewing separately obtained history
- Performing a medically necessary exam or evaluation
- Counseling and educating patient/family/caregiver
- Ordering medications, tests, or procedures
- Referring and 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 patient/family/caregiver
- Care coordination (not separately reported)
“Not separately reported” means neither practitioner submits a separate charge for the activity. When submitting the separate charge, carve out the time spent from the remainder of the E/M service.
The MD/DO and NPP may meet to discuss patient care. Use this time only once under the practitioner providing the substantive portion of the service.
Examples
- I provided the substantive portion
- This statement does not support choosing this practitioner as the billing provider
- I provided the most time
- This statement does not support choosing this practitioner as the billing provider
- I provided 30 minutes for this patient
- Use this statement to compare to the other practitioner to determine the billing provider
- Use this statement to compare to the other practitioner to determine the billing provider
E/M Component
Services 01/01/2022 through 12/31/2023 allow the MD/DO or NPP to use a component of the E/M to determine the substantive portion (excluding critical care). The components are:
- History
- Exam
- Medical Decision-Making (MDM)
There are requirements when using a component to determine the substantive portion.
- MD/DO must provide the component in its entirety
- Must use that component to choose the level of service (For services in 2022 only)
Documentation must show the MD/DO performed the E/M component. Medicare does not need the MD/DO to redocument information already contained in the patient’s medical record. This is to verify the information is correct and add any necessary updates.
Examples:
- I reviewed the NPP notes and agree – This does not support the MD/DO performed a history, exam, or medical decision-making.
- I (MD/DO) performed the history (or exam or MDM) and agree with notes in the medical record – This supports the MD/DO as the billing provider
The MD/DO must use that component to choose the level of service for services in 2022. For each category of service, the Current Procedural Terminology (CPT) identifies the required level of each component.
For example, in 2022, an initial inpatient service, code 99223 requires all three of the following components:
- Comprehensive history
- Comprehensive exam
- MDM of high complexity
A subsequent inpatient service, code 99233 requires two of the three following components:
- Detailed interval history
- Detailed exam
- MDM of high complexity
Outpatient hospital E/M codes, 99202 – 99215, use either time or MDM to choose the level of service. The substantive portion for 2022 services is the time or the MDM only.
For 2023 services, you choose the level of service based on time or MDM only. Your history or exam can determine the substantive portion of the service. This would not choose your level of service.
Unique situations
- MD/DO documents element of service
- Use the element to choose the MD/DO as the billing provider
- MD/DO documents time, the NPP does not
- Use time to choose the MD/DO as the billing provider
- The NPP documents time, the MD/DO documents an element of service,
- Use the element of service to determine MD/DO is the billing provider
- The NPP documents an element of service, the physician does not document time or an element of service
- Use the NPP as the billing provider
- The NPP and MD/DO document time
- Use the greatest amount of time to choose the billing provider
- NPP admits the patient at 9:00 PM on 01/01/23. The MD/DO sees patient the following morning 01/02/23.
- Unless a continuous service, the NPP only would submit charges for 01/01/23. This is not a split (shared) service.
- Continuous service – there is no break in care of the patient.
- Unless a continuous service, the NPP only would submit charges for 01/01/23. This is not a split (shared) service.
Modifier
Bill the E/M service under the practitioner providing the substantive portion of the service. Append modifier FS. Use modifier FS when billing under the MD/DO or the NPP.
The separate documentation by either the MD/DO or the NPP may support a level of care. Medicare requires the FS modifier when both parties work together to provide the care to the patient.
Additional Information
Split (shared) services apply to:
- New patients
- Established patients
- Initial services
- Subsequent services
One practitioner must provide a face-to-face service with the patient. This does not have to be the billing provider.
When billing prolonged services, the same rules apply. Bill under the practitioner providing the substantive portion of the service.
Both parties document their services. Medicare requires the practitioner providing the substantive portion (billing provider) to sign the medical record. Both parties can sign their own documentation. Medicare requires the billing providers to sign both documents.
Medicare’s allowed amount if 100% of the fee schedule for the service when billed under the MD/DO. The allowed amount is 85% of the fee schedule when services billed under the NPP.
Reminder: Base the level of service on the description in the CPT. This is separate from determining who provided the substantive portion.
Split (Shared) Services Resources
- CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 12 - Physicians/Nonphysician Practitioners , section 30.6.18.
- Code of Federal Regulations 42CFR415.140
global-tags: Coverage Criteria,J8B,J5B,Split/Shared Service,Evaluation and Management,Claims
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