On November 2, 2023, the Centers for Medicare & Medicaid Services (CMS) issued the calendar year 2024 Medicare Physician Fee Schedule Final Rule. Within it, CMS announced it will be adopting the American Medical Association (AMA) definition of “substantive portion” for split/shared evaluation and management (E&M) inpatient visits so that the split/shared policy aligns with CPT guidelines.
The 2024 CPT E&M guidelines indicate the following:
- A split/shared encounter is one in which a physician and other qualified healthcare professional (QHP) act as a team in providing care for the patient, working together during a single E&M service.
- The split/shared visit guidelines are applied to determine which professional may report the service. If the physician or other QHP performs a substantive portion of the encounter, the physician or other QHP may report the service.
Accordingly, per the final rule, the definition of substantive portion will be more than half of the total time spent by the physician and nonphysician practitioner (NPP) performing the split/shared visit, or a substantive part of the medical decision-making (MDM) as defined by CPT.
- The most notable change is that CMS no longer allows the documentation of history or exam in its entirety as a measure of determining which provider performed the substantive portion, since these are not included in the E&M split/share CPT code definitions.
- One key exception to the final rule definition change concerns critical care visits. Critical care visits do not use MDM, only time. As such, for critical care visits, the substantive portion will continue to mean more than half of the total time spent by the physician and NPP performing the split/shared visit.
CMS has finalized the policy for 2024 to alleviate administrative challenges that would otherwise burden practices investing time and resources in preparing for potential policy changes that are repeatedly postponed. However, CMS has emphasized that billing under the physician for split/shared visits must include documentation for how the physician participated in the care management plan, including whether they made or approved the plan for the number and complexity of problems and take responsibility for the plan and its inherent risk of complications.
It is worth noting that CMS received a variety of feedback on finalization of the policy. Some commentors requested that CMS withdraw the substantive portion policy altogether while others asked that it continue the current policy to allow use of the three key components (history, time, MDM) or time to determine who bills for the visit. Industry reaction notwithstanding, the substantive portion policy is here to stay in 2024.
ECG can provide strategies to help your organization be proactive in addressing the regulatory changes of the final rule.
Visit our Center for Split/Shared Success for continuing updates and advice.
Center for Split/Shared Success
Edited by: Matt Maslin
