Medical Practice 2022 Predictions: The Impact of the New Facility-Based Split or Shared Policy

In the 2022 Medicare Physician Fee Schedule final rule, Centers for Medicare & Medicaid Services (“CMS”) finalized requirements for what are called split-shared (aka split or shared) billing for evaluation and management (“E/M”) visits. This billing identifies visits provided by both a physician and a non-physician practitioner “(NPP”), for example a nurse practitioner or a physician assistant.

Beginning January 1, 2022, a practitioner who performs more than half the time spent on the E/M visit or performs either one of the three key components, (1) history; (2) examination; or (3) medical decision-making in its entirety can bill for the E/M. The locations allowed for billing will increase from hospital-based to any institutional setting other than a skilled nursing facility. Additionally, critical care services can be billed by the provider who spends more than half the time on the visit.

As a certified coder and auditor, I’m aware of the documentation deficiencies that currently exist in medical record documentation, which is especially prevalent in E/M visits. As such, I’m concerned that new requirements can pose additional challenges for providers and staff which can result in a combination of incorrect coding, billing and documentation deficiencies. While I understand the shift in health care delivery to include more NPPs—and agree in the practicality of these changes—I’m also aware of the impact that insufficient medical record documentation and incorrect billing can have on providers’ revenue. 

As has occurred after other regulatory changes, I expect insurance carriers to conduct periodic audits of the codes billed and request supporting medical record documentation. I also foresee front-end denials of claims if the appropriate billing practices for a specific carrier are not present. For example, while CMS has identified the appropriate modifier for services, we may still see differing requirements for commercial carriers. The resulting impact on reimbursement, both initially and due to subsequent retroactive audits, could significantly reduce collections. 

Additional insight becomes apparent when we factor-in the change in guidelines expected for facility visits in 2023. Based on current guidance, the history, exam and medical decision-making guidelines currently utilized for facilities will shift to the 2021 office and outpatient-based medical decision- making or time-based guidelines. For split-shared services specifically, total time will be the main consideration, and the provider who performs the substantive portion of the visit can bill the service. This will necessitate even further documentation requirement changes in just another year.

To mitigate imminent denials and impending audits, we advise practitioners and coders involved in current and future split-shared billing to increase their understanding of the guidelines and obtain an independent, objective review of their E/M documentation. This will be critical in keeping revenue flow consistent as well as increase ease of documentation capture, coding and billing for the practice.  Such a coding and documentation review and education program is an integral component of compliant billing in all health care practices.