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Physician assistants (PAs) and nurse practitioners (NPs), collectively known as advanced practice providers (APPs), play a vital role in healthcare across various specialties. Their responsibilities, including billing for clinical and procedural services, have evolved significantly. In particular, theCenters for Medicare and Medicaid Services (CMS) has implemented substantial changes to split/shared billing policies, impacting APPs and physicians treating patients collaboratively. To understand these changes, tracing the historical timeline that led to the evolution of split/shared billing services in the United States is essential.

Historical Background

Before 1997, CMS recognized NPs and PAs as facility support staff, reimbursed through the hospital’s cost report without Part B billing. The Balanced Budget Act of 1997 marked a pivotal shift, allowing APPs to be recognized as Part B providers. While advancing clinical practice, this change posed financial challenges as APP salaries could no longer be included in the hospital’s cost report. To address this, CMS introduced the practice of split/shared billing, enabling joint billing for Evaluation and Management (E/M) services by physicians and APPs.

The Split/Shared Practice

The split/shared practice allows E/M services jointly performed by a physician and APP to be billed at 100% of the Medicare Physician Fee Schedule (MPFS) under the physician’s name and National Provider Identifier (NPI) number. Historically, these services were often billed under the physician’s name, with minimal requirements on physician participation or documentation levels. However, as part of its annual rulemaking process, CMS updated the split/shared guidelines in 2022, introducing significant modifications.

Changes in 2022

  • Attribution of Billing

Billing should be attributed to the provider (physician or APP) who spent the substantive portion of time, defined as greater than 50%, in the patient’s care on that calendar day.

  • Critical Care and Skilled Nursing Facility Services

Critical care services and certain skilled nursing facility (SNF) services can be split/shared, and a billing modifier “FS” should be appended to all split/shared services.

  • Documentation and Billing Modifier

The rules emphasize that billing should align with the provider (physician or APP) who performed the substantive portion of time. In fact, a billing modifier “FS” is mandated for all split/shared services, enabling Medicare to identify shared services and facilitating additional scrutiny and targeted payer auditing.

  • Transition Period

The implementation of these changes began in 2022 and continued into 2023, labeled as a transitional year. In fact, critical care services, including split/shared critical care, are solely time-based during this transitional period. Meanwhile, non-critical care services can be attributed either to time or the performance of history, examination, or medical decision-making (MDM).

  • Transition to Time-Based Attribution

CMS plans to move to a solely time-based attribution model in 2024. While the 2022 rule aimed to align with current clinical practice, its impact on the team-based care model and revenue expectations remains uncertain. The shift to time-based billing raises questions about documentation expectations, potential fraud risks, and the need for clear guidance from CMS.

  • Unclear Documentation Requirements

While physicians generally bill non-critical care split/shared visits under the MDM rubric at 100% of the MPFS, but the specific documentation requirements are unclear.

Impact on Billing Practices

Under the MDM rubric, non-critical care split/shared visits are generally billed by physicians at 100% of the MPFS, provided all billing requirements are met. However, confusion persists as the rules do not clearly outline these requirements. For instance, face-to-face visits by either the physician or the APP are necessary, but the rule doesn’t specify that the billing provider must perform this part of the visit. The lack of clarity around documentation levels and the requirement for both the physician and APP to be employed by the same group has contributed to confusion within healthcare institutions.

Final Thoughts : The evolution of split/shared billing

The evolution of split/shared billing in Medicare reflects a dynamic interplay between regulatory changes, financial considerations, and the need for clarity in documentation and attribution. As CMS moves towards a time-based model, healthcare providers face challenges adapting their billing practices and ensuring compliance.

Outsourcing to 24/7 Medical Billing Services emerges as a strategic solution, offering expertise to navigate the complexities of regulatory changes. Such a professional medical billing company specializes in staying abreast of the latest guidelines, ensuring accurate billing, and mitigating the risk of non-compliance. By entrusting billing processes to these professionals, healthcare providers can streamline operations, enhance efficiency, and focus on delivering high-quality patient care. Outsourcing becomes a valuable ally in maintaining financial stability, fostering adaptability to evolving regulations, and ultimately contributing to sustained growth in the healthcare industry.

See also: Simplifying PBHS SUD Fee Schedule For Better Understanding


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