The landscape of medical billing and compliance continues to evolve, with the Centers for Medicare & Medicaid Services (CMS) and the Current Procedural Terminology (CPT) introducing significant updates to the shared or split services policy in 2024. These changes, which expand the definition of split/shared services and modify the requirements for service billing and documentation, are crucial for healthcare providers, especially physicians and non-physician practitioners, to understand and integrate into their practice. This blog post aims to dissect these updates, offering a clear guide on what to expect and how to adapt to these new regulations.
Expanded Definition of Split/Shared Services by CPT
In 2024, the CPT has broadened its definition of split/shared services. Notably, the substantive portion of a service, which determines billing eligibility, can now be defined in two ways:
- Time-Based Determination: The practitioner who spends over 50% of the total time engaged in the encounter can bill for the service. This includes all face-to-face and non-face-to-face time attributed to patient care.
- Medical Decision Making (MDM): The practitioner who either makes or approves the medical decision making during the encounter is eligible to bill.
This expanded definition is designed to provide greater flexibility and reflect the collaborative nature of modern healthcare where multiple practitioners often interact with a patient during a single visit.
CMS Requirements Update
For 2024, CMS has aligned its requirements with the updated CPT guidelines but with specific nuances:
- Removal of History and Exam Documentation: CMS no longer allows the entirety of history-taking or physical examination to determine the substantive portion, aligning with the current CPT’s focus on MDM and time.
- Delay in Implementation: The exclusive use of time for determining the substantive portion has been delayed until 2025, marking the third such postponement. This delay gives practitioners additional time to adjust to these changes.
Billing and Documentation
CMS has set clear expectations for billing and documentation:
- Documentation of MDM: The practitioner responsible for the MDM must document these decisions thoroughly to support the billing of the visit. This aligns with the principle that billing privileges should correlate closely with the responsibility for patient care outcomes.
- Differential Payment Rates: Services billed under a physician’s National Provider Identifier (NPI) are reimbursed at a higher rate compared to those billed by non-physician practitioners, emphasizing the financial implications of proper billing practices.
- Modifier Use: The HCPCS modifier FS must be used to denote a split/shared Evaluation and Management service, ensuring that such services are clearly identified and appropriately billed.
Location and Practitioner Guidelines
The 2024 updates also clarify the roles and settings for shared/split services:
- Facility vs. Non-Facility Services: CMS specifies that shared services for Medicare patients can only occur in a facility setting. For non-facility settings, the ‘incident to’ rules apply, prohibiting shared services in offices (place of service 11).
- Practitioner Eligibility: Both CMS and CPT designate specific roles to APRNs, PAs, and other qualified healthcare professionals, allowing them to perform these services under certain conditions, fostering a team-based approach to patient care.
Real-World Application and Compliance
Implementing these changes in a clinical setting requires careful planning and understanding:
- Documentation Practices: Physicians should ensure that their documentation clearly reflects their involvement in the MDM or time spent with the patient. This may include noting agreement with assessments performed by other practitioners or explicitly stating the physician’s contribution to the care plan.
- Compliance Checks: Regular audits and training sessions can help ensure that billing practices remain compliant with the new regulations. Providers should also stay updated with guidelines from their Medicare Administrative Contractors (MACs) for region-specific requirements.
Conclusion
The 2024 updates to the CMS and CPT shared/split services policies represent a significant shift towards recognizing the collaborative nature of modern healthcare delivery. Physicians and other healthcare providers must carefully review these changes, seeking clarity and assistance when needed, to ensure that their practices not only remain compliant but also optimize the potential for appropriate reimbursement. As the healthcare landscape continues to evolve, staying informed and adaptable is more crucial than ever.
This comprehensive overview should serve as a foundational guide to understanding and navigating the complexities of the new shared or split services policies, helping healthcare providers transition smoothly and effectively. For further details, accessing the full CPT and CMS guidelines is recommended, alongside consultation with healthcare compliance experts.
