By Tammie Lunceford
In the last 10 years, NPPs or Non-Physician Providers have become more prevalent in medical offices and hospitals to allow physicians to care for more patients. As the shortage of physicians continues to increase and the costs continue to rise, the NPP is a reasonable option to cover call or round in the hospital setting.
In 2022, CMS made changes to the Split-Shared visit rules which included a new FS modifier to identify visits conducted by physician/NPP teams. Split-Shared visits are only allowed in the facility setting. They are no longer an option in the office, with 2022 being a transitional year. In previous years, the NPP would perform the history, exam and some medical decision-making. Then the physician would conduct a face-to-face on the same date to finalize the visit. Even if the physician spent minimal time with the patient, he could bill for the inpatient/observation encounter. The new rules state that only one provider must see the patient face-to-face, and the documentation should indicate the elements performed by each provider. The billing provider must perform a “substantive” portion of the visit by performing the history, exam, or the medical decision-making in its entirety.
The 2023 Physician Fee Schedule finalized a second transitional year for Split-Shared visits due to the outcry of physician groups who were concerned that 2023 would impose split-shared visits billed only by total time. In 2023, the facility Evaluation & Management guidelines were updated to using medical decision-making or time as options if one provider conducts the visit. CMS is allowing history, exam, MDM or more than 50 percent of the time if the visits is split-shared.
Physicians are realizing that the only way to utilize NPPs in the hospital is to forfeit 15 percent of the revenue. Some physicians say they are involved in every decision of the inpatient visit, but utilize the NPP as a scribe. Others say that they can accept the cut in revenue if they are receiving call pay. The 2024 PFS will surely finalize billing Split-Shared visits using only total time spent by the two providers conducting the visit with whoever spent more than 50 percent of the time will billing for the visit. Physicians and NPPs are not accustomed to documenting time when conducting an E&M visit so administrators should assure training on the “substantive” portion and on how to document total time. This training should update the group Compliance Plan. The coders will likely need to review the documentation to identify visits conducted by two providers to total the time, identify the billing provider, and add the FS modifier.
Some groups are already receiving requests for documentation related to Split-Shared visits. The FS modifier is mandatory and will serve as a flag for targeted review. Specific specialties are more likely to utilize NPPs in the hospital setting, cardiology, pulmonology, urology, neurology, and orthopedics. These changes are causing great disruption in the way some groups function. There will be much discussion on how to manage this change with minimal loss of revenue, but compliance should be as important as revenue.
Split-Shared Visits can occur in the following services by physicians and NPPs in the same group.
New and Established patients (remember hospital/facility settings only in 2022
Initial and Subsequent visits
Critical Care Services,
Certain SNF visits,
Prolonged Services (excludes those related to ED and Critical Care visits)
Emergency Department (POS 23)
Discharge Management NOTE: Split-shared billing is still not allowed for procedures or consultations (99241-99255)
Tammie Lunceford is a Healthcare Consultant with Warren Averett.