The 2024 CPT Manual is available. The update includes 230 new CPT codes, 49 code deletions and 70 revisions.   The manual also includes new definitions and instructions pertinent to evaluation and management (E/M) services. 

One of the most notable changes is the AMA’s new guidance for split or shared services.   The guidance is not consistent with the Medicare rules and is likely going to add to industry confusion and frustration.

The AMA recognizes a split or shared encounter as one in which a physician and other qualified health care professional (QHP) work as a team in providing care for a patient during a single E/M service.   The split or shared visit guidelines are applied to determine which professional may report the service.  If a physician or other QHP performs a substantive portion of the encounter, the physician or other QHP may report the service.

They further state code selection may be based on the total time on the date of the encounter.  In this instance, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time.  The AMA guidance does not explicitly define “majority”.  The CMS guidance defines the substantive portion of time as more than half of the total time spent by the physician and NPP performing the split (or shared) visit.

The AMA also recognizes the performance of the substantive portion of medical decision making (MDM) may be used for determining the billing provider for a split or shared encounter.  However, the AMA guidance in this area differs significantly from the CMS guidance.  

CMS states when one of the three key components is used as the substantive portion, the practitioner who bills the visit must perform that component in its entirety in order to bill.  They further state, if MDM is used as the substantive portion, each practitioner could perform certain aspects of the MDM, but the billing practitioner must perform all portions or aspects of MDM that are required to select the visit level billed.

The AMA guidance states the performance of the substantive portion of MDM requires the physician or other QHP to make or approve the management plan for the number and complexity of problems addressed at the encounter and take responsibility for the plan with its inherent risk of complications and/or morbidity or mortality of patient management.  By doing so, the physician or other QHP has performed two of the three elements used in the code selection of the code level based on MDM. If the amount and/or complexity of data to be reviewed and analyzed is used by the physician or other QHP to determine the reported code level, assessing an independent historian’s narrative and the ordering or review of tests or documents do not have to be personally performed by the physician or other QHP, because the relevant items would be considered in formulating the management plan.  Independent interpretation of tests and discussion of management plan or test interpretation must be personally performed by the physician or other QHP if these are used to determine the reported code level by the physician or other QHP.

KEY POINTS: 

• When using time as the substantive portion, CMS says the billing practitioner must spend more than half of the total time.  The AMA says the “majority” which presumably also means more than half the total time.  
• When using MDM as the substantive portion, CMS says the billing practitioner must perform all portions or aspects of MDM required to select the visit level billed.  The AMA says the billing provider may simply “approve” the plan.
• CMS restricts split or shared billing to facility settings only.  The AMA has not limited the locations where split or shared encounters may occur.
• CMS requires the modifier FS for all split or shared encounters.  The AMA has not established a comparable modifier.
• CMS is expected to move to a time only model for 2025.  The AMA has not indicated whether they will be revising their guidance.

Providers have struggled with implementing the CMS rules and it is unlikely the newest guidance from the AMA is going to ease the provider burden.  In reality, many payers do not recognize the split or shared billing provisions and the ones that do, often follow the Medicare rules.   

As always, it will be important to understand your payer rules and determine what, if any,  actions you need to take prior to the January 1, 2024 effective date.

The CMS Final Rule is located here:  https://www.govinfo.gov/content/pkg/FR-2021-11-19/pdf/2021-23972.pdf

We are here to help.  The HBE team is available to assist you with all of your clinical documentation, coding and compliance program needs.  We routinely provide compliance partner services to large health systems as well as physician practices. Our services include:

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