The 2022 Final Rule defines split (or shared) visits as evaluation and management (E&M) visits in the facility setting that are performed in part by both the physician and a non-physician practitioner (NPP) who are in the same group, in accordance with applicable laws and regulations. Additionally, split/shared visits are further defined as those that:

• Take place in an institutional setting in which payment for services and supplies furnished incident to a physician or practitioner’s professional services is prohibited by the Centers for Medicare & Medicaid Services (CMS); and
• Are furnished in accordance with applicable laws and regulations, including conditions of coverage and payment, such that an E&M visit could be billed by either the physician or the NPP if it were furnished independently by only one of them in the facility setting (rather than as a split/shared visit.)

CMS has stated that limiting split/shared visits to institutional settings only, for which “incident to” payment is not available, would allow for improved clarity and clearly distinguish the policies applicable to such visits from the policies applicable to services furnished incident to the professional services of a physician. CMS further explained that they did not see a need to allow split/shared visit billing in the office setting, because the “incident to” regulations govern situations in which an NPP works with a physician who bills for the visit.

“Physician practices have been billing for split/shared visits in the office setting for many years now,” said Kathy Pride, Panacea Healthcare Solutions Executive Vice President for Coding and Documentation Services. “Most providers are focusing on patient care and do not necessarily read the billing regulations on a regular basis and may not be aware that the split/shared visit is no longer allowed in the office setting.”

CMS is also now including certain skilled nursing facility/nursing facility E&M visits under this definition, and for critical care, which were previously excluded from split/shared billing.

The practitioner who bills for the split/shared visit should be the practitioner who performs the substantive portion of the visit. The “substantive portion” is defined as “more than half of the total time spent by the physician and NPP performing the split/shared visit.” However, CMS is allowing one transitional year (2022) to include in the definition, noting that “the substantive portion of the visit can also be defined as one of the three key components (history, exam, or medical decision-making/MDM).” It is important to note that starting Jan. 1, 2023, time will be the sole basis for split/shared visits, and the substantive portion will be defined as “more than half of the total time.”

CMS also clarified that when one of the three key aforementioned components is used as the substantive portion in 2022, the practitioner who bills the visit must perform that component in its entirety. CMS has also clarified that only one of the practitioners must have a face-to-face (in-person) contact with the patient, but it does not necessarily have to be the practitioner who performs the substantive portion and bills for the visit. The substantive portion could be entirely with or without direct patient contact, and will be determined by the proportion of total time, not whether the time involves direct or in-person patient contact.

“A lot of the times, the guideline changes are slow to be adopted, due to the fact that the physicians are not getting the information in timely fashion,” Pride added. “Therefore, it is important that the compliance and coding leadership/education teams get the word out to the providers that the rules have changed.”

Do you and your team have a good process to readily identify and bill appropriately for self-administered drugs?

The Centers for Medicare & Medicaid Services (CMS) has had a longstanding policy excluding self-administered drugs (SADs) under the outpatient Part B benefit. Oral drugs, suppositories, and topical medications, for example, are easy enough to identify as self-administered, and medications normally administered by intramuscular injection are not usually considered self-administered. But what about drugs administered subcutaneously? Read more