How the CY 2022 PFS Final Rule Affects Split/Shared Visits and Critical Care Services
- December 15, 2021
On May 3, 2021, the Centers for Medicare & Medicaid Services (CMS) withdrew provisions for split/shared evaluation and management (E/M) visits and critical care services from the Medicare Claims Processing Manual – Internet Only Manual (IOM), Pub. 100-04, Chapter 12, Sections 30.6.1(B), 30.6.12, and 30.6.13(H). On November 2, 2021, the Calendar Year (CY) 2022 Physician Fee Schedule (PFS) Final Rule was issued, which contained new information about these services.
Split/Shared (or Shared) E/M Visits
In the CY 2022 PFS Final Rule, CMS established the following for split/shared (or shared) E/M visits:
- A split/shared E/M visit is defined as an E/M visit provided in the facility setting by a physician and a non-physician practitioner (NPP) in the same group. The visit is billed by the physician or NPP who provided the substantive portion of the visit.
- For 2022, the substantive portion can be the history, physical exam, or medical decision-making (in its entirety), or more than half of the total time (except for critical care, which, for 2022, can only be more than half of the total time). By 2023, the substantive portion of the visit will be defined as more than half of the total time spent.
- Split/shared visits can be reported for new and established patients, initial and subsequent visits.
- A new modifier (FS) will be required on claims to identify split/shared visits and to help ensure program integrity.
- Documentation in the medical record must identify the two individuals who performed the visit, and the individual providing the substantive portion must sign and date the medical record.
Critical Care Services
In the CY 2022 PFS Final Rule, CMS established the following criteria for critical care services.
When medically necessary, critical care services can be furnished concurrently to the same patient on the same day by more than one practitioner representing more than one specialty and critical care services can be furnished as split/shared (or shared) visits.
Critical care services may be paid on the same day as other E/M visits by the same practitioner or another practitioner in the same group of the same specialty if (a) the practitioner documents the E/M visit was provided prior to the critical care service at a time when the patient did not require critical care, (b) the visit was medically necessary, and (c) the services are separate and distinct, with no duplicative elements from the critical care service provided later in the day. Practitioners must report modifier 25 on the claim when reporting these critical care services.
Critical care services may be paid separately in addition to a procedure with a global surgical period if the critical care is unrelated to the surgical procedure. Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care), requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (e.g., trauma, burn cases). A new modifier (FT) has been created to identify when critical care is unrelated to the procedure. If care is fully transferred from the surgeon to an intensivist (and the critical care is unrelated), the appropriate modifiers must also be reported to indicate the transfer of care. Medical record documentation must support the claims.
While the intent behind these changes may have been to clarify and refine policies after implementing the 2021 E/M changes, the CY 2022 PFS Final Rule has sparked a series of additional questions. For instance, if split/shared visits can be reported for new and established patients, are these rules applicable in the office setting? The answer here is no. The final rule indicates split/shared visits are limited to the facility setting because incident-to rules still apply in the office setting. Therefore, the new and established patient language is in reference to the outpatient facility setting.
Questions are also circulating about what it means for the key components (history, exam, and medical decision-making) to be completed in their entirety and its impact on provider workflows. While this will need to be assessed individually, you should anticipate workflow adjustment needs for physicians and NPPs currently performing split/shared visits or critical care services. Since these changes go into effect on January 1, 2022, it is vital to be proactive and plan potential next steps.
Here are a few things to consider:
- Begin with the end in mind | The CY 2022 PFS Final Rule outlines new requirements for both 2022 and 2023. Therefore, you will need to determine if a phased approach or an all-in-one implementation plan is best. Ask yourself, “Do we need a multi-step transition plan, or should we proactively encourage the use of the 2023 guidelines from the beginning?”
- Identify your target audience | Physicians and NPPs currently reporting split/shared visits and critical care services will need to be notified of these changes and given ample time to modify their workflows, as needed. Additionally, the medical coders, billers, and auditors who review these services will need access to educational resources. Focus your efforts and resources on this target audience first.
- Show me the money | Since provider workflows are highly likely to be impacted, provider compensation concerns may arise. It will be helpful to prepare for such conversations preemptively.
- Monitor publications and announcements | Keeping a pulse on publications and announcements will be essential with any change to standard documentation and coding guidelines and regulations.
Coker Group is available to assist you with your coding and auditing needs.
- Download our summary Coding with Coker – December 2021 – Split Shared EM Visits and Critical Care Services
- Review our Coding and Documentation Assessment and Audit services
- Submit your questions and contact information to speak with our experienced consultants