2022 Medicare Physician Fee Schedule Final Rule Impact on Split E/M Visits
The CMS 2022 Medicare Physician Fee Schedule (MPFS) final rule redefined the guidelines for split (or shared) Evaluation & Management (E/M) visits in the facility setting. Here are some questions to consider as the changes begin having effects.
- Is your organization prepared for the impact of the new split (or shared) E/M final rule?
- Does your organization’s EMR system have the capabilities to track time-based documentation?
- Do your organization’s billing and charge capture processes allow for differentiation of time-based documentation?
- Does your organization need to reconsider your strategy regarding the services and locations in which non-physician providers (NPP) are deployed based on these changes?
Split (or Shared) E/M Visits
Split (or shared) E/M visits are defined as E/M visits provided in the facility setting by a physician and an NPP in the same group. Under the 2022 MPFS final rule, the visit is to be billed by the physician or practitioner who provides the substantive portion of the visit. Split (or shared) visits can be reported for new and established patients, along with initial and subsequent visits as well as prolonged services. The facility setting includes inpatient (place of service 21), outpatient (19, 22), emergency department (23), and nursing facility (31, 32). This updated rule does not apply to the office setting (11).
For calendar-year (CY) 2022, the substantive portion is defined as one of the three key components (history, exam, or medical decision making), or more than half of the total time spent by the physician and NPP performing the split (or shared) visit. In addition, it is worth noting that when one of the three key components is used as the substantive portion in 2022, the practitioner who bills the visit must perform that component in its entirety in order to bill.
Following the transitional year, by 2023, the substantive portion of the visit will be defined as more than half of the total time spent.
Critical care visits will not be considered a part of the transitional year because they are already documented by time. For critical care services furnished in CY 2022, the substantive portion will be calculated as more than half of the total time.
|E/M Visit Code||2022 Definition of Substantive Portion||2023 Definition of Substantive Portion|
|Other Outpatient Visits
(Excluding Office Visits)
|History, or exam, or MDM, or more than half of total time||More than half of total time|
|Inpatient/Observation/Hospital/Nursing Facility||History, or exam, or MDM, or more than half of total time||More than half of total time|
|Emergency Department||History, or exam, or MDM, or more than half of total time||More than half of total time|
|Critical Care||More than half of total time||More than half of total time|
Documentation & Coding Compliance for Split E/M Visits
Documentation in the medical record must identify the two individuals who performed the visit. By 2023, time spent with the patient by individual provider should be included in the documentation. The individual providing the substantive portion must sign and date the medical record.
Medicare is requiring a new modifier (FS) on claims to identify split/shared visits.
Understanding Impact on Reimbursement & Provider Productivity
Consider the following example scenario:
A physician and their nurse practitioner both see a patient in the hospital. The physician completes and documents the medical decision making (MDM) in its entirety.
In 2022, this would be billable under the physician and receive reimbursement at 100 percent of the Medicare fee schedule.
In 2023, the time spent with the patient will determine the appropriate biller and reimbursement. Imagining the same example, the nurse practitioner spends 15 minutes with the patient and the physician spends 10 minutes with the patient. Although the physician completes and documents the MDM, the nurse practitioner spends more total time with the patient. The encounter would be billed under the nurse practitioner and reimbursed at 85 percent of the Medicare fee schedule.
The corresponding wRVU would shift from the physician to the nurse practitioner, reallocating provider productivity and affecting compensation.
Key Takeaways for Organizational Readiness
- By 2023, split (or shared) E/M visits have the potential to negatively impact professional collections.
- It’s critical to evaluate current split (or shared) E/M visit workflows to understand not only who will be able to bill but how this change will affect productivity and provider compensation.
- CMS has provided the transitional year (2022) to make necessary modifications to EMR documentation to capture the required time data for split (or shared) E/M visits. This could be a significant investment of time and resources for IT as well as with your EMR vendor, so beginning this process now is imperative.
- If changes to the deployment of NPPs are considered based on the effects of the above changes, time also will be required to plan for and implement operational and clinical aspects of the redeployment.
You can view the full fact sheet on the CMS website. If you have any questions about the 2022 MPFS final rule’s effects on split E/M visits or would like help assessing the potential impacts, please submit the Contact Us form below or reach out to your BKD Trusted Advisor™.