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Revised Guidelines for Split (or Shared) E/M Visits and Critical Care Services

On November 2, 2021, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that includes updates on policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, on or after January 1, 2022. In the final rule of the 2022 Medicare Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) made several changes to their longstanding policies for split (or shared) evaluation and management (E/M) visits and critical care services. In this article, we shared these revised guidelines for split (or shared) E/M visits and critical care services. 

Split (or Shared) E/M Visits

CMS is refining their longstanding policies for split (or shared) E/M visits to better reflect the current practice of medicine, the evolving role of non-physician practitioners (NPPs) as members of the medical team, and to clarify conditions of payment that must be met to bill Medicare for these services. In the CY 2022 PFS final rule, CMS is establishing the following:

  • Definition of split (or shared) E/M visits as E/M visits provided in the facility setting by a physician and an NPP in the same group. The visit is billed by the physician or practitioner who provides the substantive portion of the visit.
  • By 2023, the substantive portion of the visit will be defined as more than half of the total time spent. For 2022, the substantive portion can be history, physical exam, medical decision-making, or more than half of the total time (except for critical care, which can only be more than half of the total time).
  • Split (or shared) visits can be reported for new as well as established patients, and initial and subsequent visits, as well as prolonged services.
  • A modifier is required on the claim to identify these services to inform policy and help ensure program integrity. 
  • According to CMS, documentation should identify the two individuals who performed the visit, and the individual providing the substantive portion must sign and date the medical record. However, these documentation guidelines may also create a discrepancy between who performs the substantive part of the work (and thus bills for the service) and who documents the E/M visit.
  • Codifying these revised policies in a new regulation at 42 CFR 415.140.

Critical Care Services

For critical care services, CMS is refining their longstanding policies, establishing that:

  • Critical care services are defined in the CPT Codebook prefatory language for the code set.
  • The CPT Codebook listing of bundled services is not separately payable.
  • When medically necessary, critical care services can be furnished concurrently to the same patient on the same day by more than one practitioner representing more than one specialty, and critical care services can be furnished as split (or shared) visits. 
  • Critical care services may be paid on the same day as other E/M visits by the same practitioner or another practitioner in the same group of the same specialty, if the practitioner documents that the E/M visit was provided prior to the critical care service at a time when the patient did not require critical care, the visit was medically necessary, and the services are separate and distinct, with no duplicative elements from the critical care service provided later in the day. Practitioners must report modifier -25 on the claim when reporting these critical care services. 
  • Critical care services may be paid separately in addition to a procedure with a global surgical period if the critical care is unrelated to the surgical procedure. Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (e.g., trauma, burn cases). CMS is creating a new modifier for use on such claims to identify that the critical care is unrelated to the procedure. If care is fully transferred from the surgeon to an intensivist (and the critical care is unrelated), the appropriate modifiers must also be reported to indicate the transfer of care. Medical record documentation must support the claims.

You need to understand these revised guidelines properly to receive accurate Medicare reimbursement for split (or shared) visits and critical care services. If you need any assistance in billing for Medicare, contact MedicalBillersandCoders (MBC). Our billing experts stay on top of Medicare billing guidelines as per medical specialty to receive accurate reimbursements. To know more about our Medicare billing and coding services, contact us at info@medicalbillersandcoders.com/ 888-357-3226

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