Reporting Split/Shared E/M Visits in 2024

A split/shared visit is an E/M visit in a hospital or other facility setting that is performed in part by both a physician and an NPP who are in the same group practice. A split/shared E/M visit may be provided to a new or established patient for an initial or subsequent visit.

No. This new split/shared E/M visit reporting policy applies only to those furnished in a facility setting. In a nonfacility setting, such as a physician’s office, different reporting rules apply when an NPP provides some or all of an E/M visit and the physician bills for the visit. This type of E/M visit is referred to as an "incident-to" service.

Medicare defines an NPP as a nurse practitioner, physician assistant, certified nurse specialist, or certified nurse midwife. All of these practitioners may independently report E/M services if they are legally authorized and qualified to furnish an E/M service in their state. NPPs who care for Medicare patients in a facility must enroll in the Medicare program to bill for the services they provide.

CMS has yet to provide a definition of "same group" at this time, but has indicated that a physician and an NPP must work jointly to furnish all of the work related to the E/M in circumstances when a split/shared visit is appropriately billed. If a physician and NPP are in different groups, the physician and NPP would be expected to bill independently and only for the services each fully furnishes.

CMS has adopted the following Current Procedural Terminology (CPT^®) guidelines for reporting a split/shared E/M visit:

If the physician or other QHP¹ performs a substantive portion of the encounter, the physician or other QHP may report the service. If code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service. For the purpose of reporting E/M services within the context of team-based care, performance of a substantive part of the MDM requires that the physician(s) or other QHP(s) made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management. By doing so, a physician or other QHP has performed two of the three elements used in the 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.²

CMS relies on the list of activities included in CPT E/M Guidelines that count toward total time for purposes of who reports the split/shared visit and for the level of code selected. Based on these guidelines, physician/NPP time includes the following activities:

• Preparing to see the patient (such as 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)

Physician/NPP time does not include the following activities:

• Performance of other services that are reported separately
• Travel
• Teaching that is general and not limited to discussion that is required for the management of a specific patient

No. For all split/shared E/M visits, only one of the practitioners must have 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. When reporting a split/shared visit using total time, the substantive portion could be provided entirely with or without direct patient contact and will be determined based on the proportion of total time, not whether the time involves direct or in-person patient contact.

Yes. If code selection is based on total time on the date of the encounter, the service is reported by the physician/NPP who spent the majority of time performing the service.

CMS has not yet released specific documentation requirements for reporting a split/shared E/M visit. However, it is best practice that the medical record identify the two practitioners who performed the split/shared visit, the activities each practitioner performed, and the time spent by each practitioner. In addition, the individual who performed the substantive portion—and therefore bills the visit—must sign and date the medical record. CMS has emphasized that, although any member of the medical team may enter information into the medical record, only the reporting provider may review and verify notes made in the record by others for the services the reporting clinician furnishes and bills.

The new split/shared E/M visit guidelines indicate that performance of a substantive part of the MDM requires that the physician or NPP who will bill the visit made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or the morbidity or mortality of patient management. By doing so, a physician or NPP has performed two of the three elements used in the selection of the code level based on MDM.

Yes. CMS requires that HCPCS modifier –FS (Split or shared E/M visit) be appended to the facility claims for split/shared E/M visits, no matter if the physician or NPP bills for the visit. This modifier does not apply to incident-to office visits.

No. Critical care E/M services (e.g., CPT codes 99291-99292) are reported based solely on time. MDM is not a component of these CPT codes.