The AMA Current Procedural Terminology (CPT) guidelines for split or shared visits were recently updated and implemented as of Jan. 1, 2024. These revisions aim to clarify and streamline the billing process for split or shared evaluation and management (E/M) services, ensuring clarity on which provider — either the physician or qualified health care professional — is authorized to bill for the service rendered.

A split or shared visit is now defined by the “substantive portion” of the E/M service provided. This substantive portion can be determined in two ways:

  • Time-Based: The substantive portion is based on the majority (over 50%) of the total clinical care time given in the visit by both the physician and accompanying qualified health care professional.
  • Medical Decision Making (MDM): The substantive portion can also be determined by an essential part of the MDM process.

Therefore, as of Jan. 1, 2024, Medicare will pay for a split or shared E/M visit at the rate of the provider who either:

  • Spent more than half of the total time spent by the providers performing the visit.
  • Performed a substantive part of the medical decision-making.

Time-Based

The following activities can be counted toward total time for purposes of determining the substantive portion of the E/M service provided:

  1. Preparing to see the patient (e.g., reviewing tests)
  2. Obtaining and/or reviewing a separately obtained history
  3. Performing a medically appropriate examination and/or evaluation
  4. Counseling and educating the patient/family/caregiver
  5. Ordering medications, tests, or procedures
  6. Referring and communicating with other health care professionals (when not separately reported)
  7. Documenting clinical information in the medical record
  8. Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
  9. Care coordination (not separately reported)

You must be able to tell from the documentation who performed these elements to determine who bills. Do not count time spent on the following:

  1. Performance of other services that are reported separately
  2. Travel
  3. Teaching that is general and not limited to the management of a specific patient

Medical Decision Making

For the physician to be reported as the billing provider for a shared E/M service based on MDM, the 2024 CPT guidelines require the following:

  • The physician must create or approve the management plan for the patient.
  • The physician must assume responsibility for that plan, including its inherent risk of complications, morbidity, or mortality.

This means that providers can bill for a physician’s service in a split or shared visit even if the physician did not spend more than half of the time with a patient. Instead, the physician must have performed a “substantive portion” of the MDM, such as developing the plan of care and assuming responsibility for the patient. By meeting these requirements, the physician fulfills two of the three key elements for choosing the appropriate E/M code based upon MDM.

CPT states that for shared service MDM scoring, the physician is not required to perform these actions, which contribute to the creation of the management plan:

  • Interview the independent historian personally.
  • Order and or review tests or external documents.

However, CPT does require that the physician must personally perform any independent interpretations and external discussions when these are used in determining the reported E/M level.

The 2024 updates to the CPT guidelines for split or shared services aim to provide clarity and streamline the billing process for these services. By defining the substantive portion of the E/M service and outlining the billing requirements for physicians, these guidelines seek to ensure that health care providers can accurately and appropriately bill for split or shared visits, which will benefit both providers and patients.

Case

A 47-year-old man with chronic obstructive pulmonary disease is admitted to the hospital due to an exacerbation of his condition. The nurse practitioner (NP) from the pulmonologist’s group sees the patient in the morning. The NP reviews the patient’s medical history, performs a physical examination, and makes preliminary decisions about the patient’s treatment plan.

Later in the day, the pulmonologist sees the patient, reviews the NP’s notes, examines the patient, adjusts the treatment plan based on this assessment, and documents findings and changes to the treatment plan in the patient’s medical record.

Discussion

In this case, the pulmonologist performed a substantive portion of the E/M visit by adjusting and approving the treatment plan, which is a key component of MDM. Therefore, the E/M visit can be billed under the pulmonologist’s name and NPI.

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