New Guidelines for Coding Split (or Shared) E/M Visits and Critical Care Services

In the final rule of the 2022 Medicare Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) made several changes to their longstanding policies for split (or shared) evaluation and management (E/M) visits and Critical Care Services. Policies related to these two areas recently had been removed from the Medicare Internet-Only Manual (IOM) in response to a petition to the U.S. Department of Health & Human Services (HHS).

Here’s an overview of the new policies, along with some documentation and coding suggestions.

Split (or Shared) E/M Visits

According to CMS, refinements of the policies for split (or shared) E/M visits will help “better reflect the current practice of medicine, the evolving role of non-physician practitioners (NPPs) as members of the medical team, and to clarify conditions of payment that must be met to bill Medicare for these services.”

Among the changes, CMS is adopting the following definition of a split (or shared) E/M visit: “a visit provided in a facility setting in which a physician and other qualified healthcare professional(s) jointly provide the face-to-face and non-face-to-face work related to the visit.”

While split (or shared) E/M visits are no longer allowed in an office setting, they can be reported for new as well as established patients, and initial and subsequent visits, as well as prolonged services and critical care services. Also, a modifier will be required to report a split (or shared) E/M visit, though CMS has not yet specified which modifier will be used.

In addition, only one of the practitioners must provide in-person care, but the billing should be done by the practitioner who provides the “substantive portion” of the visit. If the physician bills for the visit, they would receive the full payment amount from the Medicare Physician Fee Schedule (MPFS). However, NPPs receive only 85 percent of the MPFS payment amount.

Defining the Substantive Portion

For 2022, the substantive portion of a split (or shared) E/M visit can be determined based on one of two methods:

more than half of the total time spent OR
one of the three key components (history, exam, or medical decision making [MDM]).

When one of the three key components is used, the practitioner who bills the visit must perform that component in its entirety, or at minimum, must perform the component to the level required at the visit level billed.

Beginning in 2023, the substantive portion of the visit will be defined only as more than half of the total time spent. For critical care services, however, the substantive portion of the visit will be defined only as more than half of the total time spent beginning in 2022.

CMS also finalized the following list of activities that can count when determining time, regardless of whether or not they involve direct patient contact. This list would also apply within the emergency department setting, though not for critical care services, which has its own list of activities:

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 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 the patient/family/caregiver.
Care coordination (not separately reported).

Practitioners would not count time spent on the following:

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

There may be some discrepancy between how the substantive portion of the E/M is determined and how the E/M level is chosen. According to CMS, providers can continue to select the visit level for the E/M split (or shared) visit based on MDM, even though the substantive portion of the visit is determined based on time (or vice versa). Also, in emergency departments, providers can use time to determine the substantive portion of split (or shared) visits (and will be required to do so in 2023), even though code selection is based on a combination of history, exam, and medical decision making.

Documenting a Split (or Shared) Visit

According to CMS, documentation in the medical record for a split (or shared) E/M visit should identify the two individuals who performed the visit, and the individual providing the substantive portion must sign and date the medical record. However, these documentation guidelines may also create a discrepancy between who performs the substantive part of the work (and thus bills for the service) and who documents the E/M visit.

For instance, is it sufficient for the physician to perform the substantive part of the visit, sign the chart, and bill for the service, even if the NPP provides the documentation? What about facilities that require the attending physician to sign NPP charts regardless of their participation in the visit? How will coders know which should be billed as shared visits or simply as NPP visits?

According to Jenn Sheese, COC, CPC, CPMA, CEDC, CIPROMS Auditor and Medical Coder, these are all questions that have remained unanswered by CMS so far.

“We will continue to check for any updates in the documentation requirements,” Sheese said. “At this time, we have provided examples of attestations that we believe will clearly support when a physician performs a substantive portion and allow us to bill the encounter for the physician.”

In fact, the following attestation examples could be used by either physicians or NPPs for clarity to indicate who performed the substantive portion of the E/M:

“I provided a substantive portion of the care of this patient. I personally performed the _____________ for this encounter.” (Insert History or Exam or Medical Decision Making)
“I provided a substantive portion of the care of this patient. I personally performed the _____________ for this encounter.” (Insert History or Exam or Medical Decision Making, followed by documentation of the Hx, exam or MDM to the extent needed to support the assigned E&M code. NOTE: This is a regression in previous policies that aimed to relieve the duplicative documentation burden.)
“I provided a substantive portion of the care of this patient. I personally provided more than half of the total time dedicated to treatment of this patient.”

Critical Care Services

The guidelines for billing Critical Care Services also was updated in the final rule of the 2022 Medicare Physician Fee Schedule. Among the changes, CMS will now use the American Medical Association (AMA) Current Procedural Terminology (CPT) prefatory language as the definition of critical care visits, including bundled services.

As well, the new guidelines specify that critical care services can be furnished as split (or shared) visits, or furnished along with many other services on the same day, including the following:

Critical care services can be furnished concurrently to the same patient on the same day by more than one practitioner representing more than one specialty.
Critical care services can be furnished on the same day as other E/M visits by the same practitioner or another practitioner in the same group of the same specialty, if a.) the practitioner documents that the E/M visit was provided prior to the critical care service at a time when the patient did not require critical care, b.) the visit was medically necessary, and c.) the services are separate and distinct, with no duplicative elements from the critical care service provided later in the day. Practitioners must report modifier -25 on the claim when reporting these critical care services.
Critical care services can be furnished separately in addition to a procedure with a global surgical period if the critical care is unrelated to the surgical procedure. Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (e.g., trauma, burn cases). A new modifier will be created for use on such claims to identify that the critical care is unrelated to the procedure. If care is fully transferred from the surgeon to an intensivist (and the critical care is unrelated), the appropriate modifiers must also be reported to indicate the transfer of care.

Learn More

For more information about the new guidelines for coding and billing split (or shared) E/M visits and critical care services, check out the following resources: