If your healthcare organization utilizes split/shared billing, your organization could be at risk without proper training and attestation to support services billed correctly. If you are unfamiliar with split/shared services, it’s the practice of two providers: a physician and a qualified healthcare professional (QHP) see a patient on the same day, and one of them decides to bill based on a “discussion” with the QHP as well as attestation of the QHP note. As such, the Centers for Medicare & Medicaid Services (CMS) has modified guidelines with documentation requirements as well as the elements of medical decision-making related to the care provided. The Final Rule was published in the November 18, 2022, Federal Register—an annual publication of confirmed regulatory requirements to bill these and other types of services to CMS.[1] It explained how the proper documentation requirements to bill for split/shared services would be granted another year extension from calendar year (CY) 2023 to CY 2024. This means that when split/shared services are billed, documentation requires—per CMS—the physician or the QHP to detail a substantive portion through history, examination, or medical decision-making (MDM) more than half of the total time. CMS intends to change the documentation from history, examination, or MDM to only total time beginning in CY 2023. With this additional year in place, organizations have more time to train their providers of services to meet these regulatory requirements.
What exactly is split/shared billing?
CMS finalized a major change regarding services performed in a facility setting when both the QHP and physician make rounds with the same patient on the same calendar date—otherwise known as a split/shared visit. This occurs when a physician and a QHP of the same specialty/subspecialty perform an evaluation and management (E/M) service on the same calendar date; if these services are performed on a different date, it is not considered split/shared. This is demonstrated by who is performing the most work while rounding (greater than 50%); according to CMS’s definition of substantive portion, the greater than 50% must be in the form of MDM or time, which must be explicitly documented via the attestation written by the physician. The QHP typically does not bill for the work they performed, and the physician, in turn, bills for the service based on the appropriate attestation for their participation in patient care.
What has CMS changed when I bill split/shared services?
CMS changed how split/shared services are used effective January 1, 2022, and will change how the physician attests as well as what is supported when documented.[2] CMS uses the term “substantive portion” to specify what should be documented when determining the substantive portion (greater than 50%), which is much different from years prior as it only required an attestation for the physician to receive a credit to bill. Now, CMS has changed its requirements dramatically.
Here is the breakdown of how split/shared services are reimbursed when billed by an medical doctor or QHP:
When a physician bills
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When a physician bills for split/shared services, the bill is paid at 100% of the Medicare Physician Fee Schedule (MPFS)
When a QHP bills
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When a QHP bills for split/shared services, the bill is paid at 85% of the MPFS
Other items to consider when split/shared services are billed
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An encounter is shared between a physician and QHP from the same group specialty/subspecialty
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The same employer employs both QHP and doctor (note that this would not apply to medical students or residents)
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When encounters are submitted to the bill, they are submitted with the modifier FS when performed in one of the following places of service:
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Hospital inpatient
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Hospital observation
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Outpatient hospital outpatient departments
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Hospital discharge services
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Emergency department
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Critical care services
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Prolonged services
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