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Published 5/2/2022
Sarah Wiskerchen, MBA, CPC

CMS Updates Physician Assistant and Nurse Practitioner Billing

Editor’s note: This article is part one of a two-part series focusing on the 2022 Centers for Medicare and Medicaid Services (CMS) updates to physician assistant (PA) and nurse practitioner (NP) billing. Part two was published in the AAOS Now June 2022 issue. 

In January, CMS introduced guideline changes to its Medicare reporting rules that impact PA/NP billing. These changes could require practices to modify how they report split/shared services. Previously, shared services were frequently reported in the name of a physician. Now, new rules determine who can report the services. Failing to comply with the new CMS rules will create compliance risks for physician practices.

This article outlines what has changed for split/shared billing, as well as what CMS indicates is ahead for 2023. Part 2 of this series will answer common questions related to shared services and underscore important policy changes.

Key changes
The final changes to the split/shared services guidelines were published in the Federal Register on Nov. 19, 2021, and were replaced in Chapter 12 of the Medicare Claims Processing Manual in January. There were eight key changes.

No. 1: Split/shared billing—facility setting
“Split (or shared)” visits are now defined as evaluation and management (E/M) visits in the facility setting that are performed in part by both a physician and nonphysician practitioner (NPP) in the same group. According to CMS, a facility setting means an institutional setting; this could apply to inpatient hospital locations, outpatient hospital locations, observation, the ED, or a skilled nursing facility for selected services.

No. 2: Split/shared billing—office/clinic settings
Chapter 12 no longer includes an office/clinic example. Prior to May 2021, the text of Chapter 12 included an example of split/shared billing in an office/clinic which stated that incident-to requirements had to be met before split/shared rules could be considered. In the Federal Register, CMS reiterated that if a split/shared visit is performed in an office setting, incident-to criteria must be met.

Office/clinic settings are not all treated the same for billing purposes. Private practices typically report office services using place of service 11 (office), which is not a facility setting. As such, those locations could use incident-to reporting but are not allowed to apply CMS’ split/shared rules. Hospital-owned or academic practices may instead classify their offices as place of service 19 (off-campus outpatient hospital) or place of service 22 (on-campus outpatient hospital). These locations are not allowed to use incident-to reporting but could apply CMS’ split/shared rules.

No. 3: Defining the substantive portion
The physician and the PA/NP must each provide a portion of the service with the patient on the same day and document their respective work. The service must be billed by the provider who performs the “substantive portion” of the visit.

Previous guidelines also required that both providers provide face-to-face service with the patient on the visit date. The guidance for how much work the physician was required to perform to allow billing was not explicitly described: Chapter 12 said that if the physician provided “any face-to-face portion of the E/M encounter with the patient” that it could be reported by either provider. Now, CMS is using the substantive portion as the determining factor for billing and has defined how the substantive portion can be assigned.

During 2022, two methods can be used to determine which provider is assigned for billing:

  • method 1: based upon the provider who performed greater than 50 percent of the time of the visit
  • method 2: based upon the provider who performed either the history, or the exam, or the medical decision-making (MDM) portion of the note, in its entirety

Method 2 is only an option for 2022. In 2023, only method 1 will apply. CMS stated that beginning in 2023, greater than 50 percent of the total time of the visit will be the only method used to determine the substantive portion of split/shared visits for all categories of E/M.

In explaining the second method, Chapter 12 states: “For example, if history is used as the substantive portion and both practitioners take part of the history, the billing practitioner must perform the level of history required to select the visit level billed. If physical exam is used as the substantive portion and both practitioners examine the patient, the billing practitioner must perform the level of exam required to select the visit level billed. If MDM is used as the substantive portion, each practitioner could perform certain aspects of MDM, but the billing practitioner must perform all portions or aspects of MDM that are required to select the visit level billed.”

The challenge with this instruction during 2022 is that two sets of criteria are used for determining the level of E/M services. For categories of services such as initial and subsequent hospital care (99221-99233) and ED visits (99281-99285), Current Procedural Terminology (CPT) rules continue to require a combination of history, examination, and MDM to determine the visit level. For these codes, it is straightforward to use either of the new CMS methods to determine the substantive portion for split/shared visits.

For office/outpatient visit codes 99202-99215 that could be used in place of service 19 or 22 offices, CPT guidelines use either time or MDM to determine the level of service. However, these guidelines use different definitions and parameters from other E/M services. Because history and exam are no longer used to select the visit level, the second CMS method for determining the substantive portion is unclear. Because 99202-99215 CPT code levels can be determined based on MDM alone, that element fits best if the second method is used to determine the substantive portion.

Although this is not stated in the Chapter 12 text, during explanatory webinars, CMS indicated that the method used to determine the level of service does not have to be the method used for determining the substantive portion of the visit.

No. 4: Criteria for counting time
CMS is using CPT’s 2021 E/M guidelines for codes 99202-99215 to define the activities that can be counted toward total time when determining the substantive portion of the visit, whether or not they involve direct patient contact.

This is another area where the impact of two sets of CPT E/M criteria is felt: Although the CPT rules for hospital-used codes such as 99221-99233 and 99281-99285 state that unit/floor time can be counted toward visit time, they do not explicitly use this list of qualifying services to determine the level of service. Since 2021, CPT has used this list to determine the level of service for E/M codes 99202-99215, but now CMS has stated it can also be used to determine the substantive portion of other E/M categories.

No. 5: Face-to-face contact
CMS now requires that only one of the providers has face-to-face contact with the patient; it is no longer required of both providers. Furthermore, it is not required that the provider who performs the substantive portion has face-to-face contact.

No. 6: Documentation and signature
The revised guidelines state that the documentation in the medical record must identify the physician and NPP who performed the visit, and that the individual who performed the substantive portion of the visit must sign and date the medical record. AAOS believes it is best practice for all providers to authenticate/sign their documentation, even if not required by CMS.

No. 7: New modifier
Beginning in 2022, split/shared services must be reported with a new modifier, FS. Note that this requirement does not apply only to split/shared services billed in the name of the physician; if a visit is shared by a physician and PA/NP and the PA/NP performs the substantive portion, CMS still requires the use of modifier FS.

No. 8: Prolonged services
During 2022, the CPT codes for prolonged services will depend on the setting. In all settings, the combined time of both practitioners must meet the criteria for the appropriate code, G2212 in the office setting and codes 99354-99359 for other inpatient/outpatient codes, and either method 1 or 2 can be used to determine the substantive portion. In 2023, only the time method will be used to determine the substantive portion.

What about other payers?
As in the past, organizations should apply Medicare policies only to Medicare patients and should research both state-specific Medicaid guidelines and payer-specific rules to confirm how they compare to Medicare’s revised guidelines.

CMS’ split/shared rule changes add new levels of complexity and compliance risk to PA/NP billing. Practices must pay attention to the detailed requirements, including the use of the modifier FS. Starting in 2023, across all settings, the billing provider will be determined by who performs greater than 50 percent of the split/shared service.

Information in this article has been reviewed by the members of the AAOS Coding Coverage and Reimbursement Committee.

Sarah Wiskerchen, MBA, CPC, is a senior consultant with KarenZupko & Associates, Inc.

1. Wiskerchen S: Billing essentials for using a PA or NP in orthopaedics. AAOS Now. February 2015.
2. Wiskerchen S: PA and NP billing: are you doing it correctly? AAOS Now. May 2016.