|The 2024 Medicare Physician Fee Schedule Final Rule was released today. |
In a shocking turn of events, CMS announced in the Final Rule they will be adopting the 2024 AMA definition of substantive portion for split (or shared) visits. Specifically, CMS stated, “we are finalizing a policy that reflects a revised definition of “substantive portion” of a split (or shared) visit to reflect the revisions to the CPT E/M guidelines, such that for Medicare billing purposes, the “substantive portion” means more than half of the total time spent by the physician and NPP performing the split (or shared) visit, or a substantive part of the medical decision making except concerning critical care visits which do not use MDM and only use time, “substantive portion” continues to mean more than half of the total time spent by the physician and NPP performing the split (or shared) visit.
For 2024, 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.
The AMA indicates 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.
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.
The Final Rule does not include changes to the following requirements: CMS restricts split or shared billing to facility settings only. CMS requires the modifier FS for all split or shared encounters. Organizations have struggled with appropriate documentation and billing of split (or shared) encounters for the last couple of years. The reimbursement impact of performing split (or shared) encounters has caused significant frustration for physicians and NPPs alike.
Implementation of the newest guidance and re-education for providers and coders prior to January 1, 2024 effective date is going to be difficult to achieve for most organizations.
The 2024 Final Rule is located here: https://public-inspection.federalregister.gov/2023-24184.pdf
CMS Makes Major Change to Split/Shared Rule for 2024 November 2, 2023