The 2022 CMS Final Medicare Physician Fee Schedule (MPFS) contains substantial changes to the split/shared and critical care rules. These changes impact both office/outpatient and inpatient settings and require a closer look to understand the requirements and expected operational and financial impact.
- Payment for split/shared services will be limited to institutional settings only.
- The billing provider for critical care split/shared services will be based on the performance of the substantive portion (more than ½ of the total time) of the encounter.
- The billing provider for non-critical care split/shared services will be based on the performance of the substantive portion (more than ½ of the total time) of the encounter effective January 1, 2023.
- For calendar year 2022, the substantive portion of the encounter will be determined based on time OR the performance of one of the 3 key components (history, exam or MDM).
- Critical care and prolonged services may be performed and billed as split/shared services.
- New documentation requirements for split/shared services.
- New modifier for reporting split/shared services.
- New bundling rules for services rendered on the same date as critical care.
- New modifier to identify critical care services as unrelated to global surgical services.
- Time spent by multiple providers within the same group and specialty may be aggregated to satisfy the time-based requirements for critical care.
- Split/shared– An E/M visit in the facility setting that is performed in part by both a physician and an NPP who are in the same group.
- Institutional (facility) setting– A hospital or skilled nursing facility.
- Substantive portion– More than half of the total visit time and may be comprised of time that is with or without direct patient contact.
- Qualifying time– Time spent performing activities which may be counted towards E/M time. The activities which may be counted are defined by CPT.
- Split/shared encounters may only be performed in an institutional (facility) setting. Services performed in an office setting are subject to the “incident to” rules defined at 42 CFR §410.26.
- Split/shared encounters may be provided for the following E/M categories:
- New patient encounters
- Established patient encounters
- Initial hospital care encounters
- Subsequent hospital care encounters
- Skilled nursing care encounters which are not statutorily defined as “physician only” encounters
- Critical care encounters
- Prolonged service encounters
In addition to the standard medical record documentation guidelines, the following requirements apply to split/shared encounters:
- The documentation must readily and clearly identify which service(s) were performed by each provider and establish each provider’s role in rendering care.
- Both providers must indicate the personal time spent in care of the patient.
- Time is not required to be documented as start/stop but it is recommended.
- The documentation must support at least one of the providers had a face-to-face (in person) encounter with the patient but it does not necessarily have to be the provider who performed the substantive portion and bills for the visit.
- For non-critical care encounters, if history, exam or MDM is used as the substantive portion of the encounter in lieu of time, the documentation must reflect the billing provider performed the component in its entirety.
- Overlapping time may not be counted.
- The documentation must support the service(s) performed.
- The record must be authenticated by the provider who performed the “substantive portion” of the encounter.
- The documentation must support the services rendered by both providers were reasonable and necessary.
|E/M Category||2022 Definition of Substantive Portion||2023 Definition of Substantive Portion|
|Outpatient (other than office)||History, or exam, or MDM or more than ½ of total time||More than ½ of total time|
|Inpatient/Observation/Hospital/Nursing Facility||History, or exam, or MDM or more than ½ of total time||More than ½ of total time|
|Emergency Department||History, or exam, or MDM or more than ½ of total time||More than ½ of total time|
|Critical Care||More than ½ of total time||More than ½ of total time|
- The billing provider must be the provider who performed the substantive portion of the encounter.
- A new modifier will be required to identify all split/shared encounters.
- Code selection for critical care services is based on the total time spent by both the NPP and the physician. The distinct time of service spent by each NPP and physician time is summed together to determine the total time as well as who performed the substantive portion of the encounter.
- Code selection for non-critical care services is based on either the documented MDM or the total time by both the NPP and the physician.
- Prolonged services may be reported by the practitioner who reports the primary service when the combined time of both practitioners meets the threshold for reporting prolonged E/M services.
- Overlapping time may only be counted once.
- Activities which may be counted towards the total reported time for non-critical care services are defined by CPT and can be located within the CPT manual and are also attached to this summary.
- Activities which may be counted towards the total reported time for critical care services are also defined by CPT and can be located within the CPT manual and are also attached to this summary.
- Initial critical care may only be reported once per day for services rendered by providers within the same group and specialty. Additional critical care time may be reported by utilizing the add-on code if the CPT reporting requirements are satisfied.
- All critical care time spent by a physician or NPP on a date may be aggregated even if the time spent is not continuous.
- Continuous critical care services that last beyond midnight (cross range of dates) should be reported as the total units of time provided continuously.
- Providers may separately report E/M services provided on the same day as critical care if the service was provided prior to critical care at a time when the patient did not require critical care and the services rendered were not duplicative of any critical care service provided later in the day. Modifier 25 must be reported.
- Providers may separately report critical care services in addition to a global surgical procedure as long as the critical care service is unrelated to the procedure. CMS is creating a new modifier to identify claims with critical care unrelated to a global surgical procedure.
The Final Rule is available here: https://www.federalregister.gov/public-inspection/2021-23972/medicare-program-cy-2022-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part
The Fact Sheet is available here: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2022-medicare-physician-fee-schedule-final-rule
Activities which may be counted towards the total reported time for non-critical care services include the following:
- Preparing to see the patient (e.g. 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)
Activities which may be counted towards the total reported time for critical care services include the following:
- Time spent with engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit
- Time spent on the unit or nursing station on the floor reviewing test results or imaging studies
- Discussing the critically ill patient’s care with other medical staff or documenting critical care services in the medical record
- When the patient is unable or lacks capacity to participate in discussions, time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient’ s condition or prognosis, or discussing treatment or limitations(s) of treatment so long as that conversation bears directly on the management of the patient
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