Physician assistants (PAs) and nurse practitioners (NPs), generally known as advanced practice professionals (APPs), perform critical roles in a variety of specializations in healthcare. Their responsibilities, which include billing for clinical and procedural treatments, have greatly evolved. The Centers for Medicare and Medicaid Services (CMS) has made significant modifications to split/shared billing procedures, which affect APPs and physicians who treat patients cooperatively. To comprehend these changes, it is necessary to trace the historical history that led to the evolution of split/shared billing services in the United States.

Prior to 1997, CMS considered NPs and PAs as facility support workers, and they were reimbursed through the hospital’s expense report rather than through Part B billing. The Balanced Budget Act of 1997 signaled a watershed moment by allowing APPs to be recognized as Part B providers. While this adjustment advanced clinical practice, it presented financial issues because APP pay could no longer be included in the hospital’s expense report. To remedy this, CMS implemented split/shared billing, which allows physicians and APPs to bill for Evaluation and Management (E/M) services jointly.

The split/shared practice permits E/M services conducted jointly by a physician and APP to be billed at 100% of the Medicare Physician Fee Schedule (MPFS) under the physician’s name and NPI number. Historically, these services were frequently billed in the name of the physician, with few restrictions on physician participation or documentation standards. However, CMS changed the split/shared criteria in 2022 as part of its annual rulemaking process, introducing major changes.

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Billing should be attributed to the provider (physician or APP) who spent the majority of the time in the patient’s care on that calendar day, defined as more than 50%.

Critical care services and certain skilled nursing facility (SNF) services can be split/shared, and all split/shared services should have the billing modifier “FS” applied to them.

The regulations highlight that billing should be assigned to the provider (physician or APP) who did the majority of the work. In fact, for all split/shared services, a billing modifier “FS” is required, allowing Medicare to identify shared services and permitting enhanced scrutiny and targeted payer auditing.

These adjustments went into effect in 2022 and continued into 2023, which was designated as a transitional year. During this transitional period, critical care services, including split/shared critical care, are exclusively time-based. Non-critical care services, on the other hand, can be linked to either time or the performance of history, examination, or medical decision-making (MDM).

CMS intends to transition to a completely time-based attribution methodology by 2024. While the 2022 rule’s goal was to match with current clinical practice, its impact on the team-based care model and revenue projections is still unknown. The transition to time-based billing raises concerns about documentation requirements, potential fraud risks, and the need for CMS to provide clear advice.

While physicians generally bill non-critical care split/shared visits at 100% of the MPFS under the MDM rubric, the particular documentation requirements are unclear.

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Non-critical care split/shared visits are normally billed at 100% of the MPFS under the MDM rubric, assuming all billing standards are followed. However, there is still misunderstanding because the guidelines do not precisely state these needs. Face-to-face visits by either the physician or the APP, for example, are required, but the rule does not stipulate that the billing provider must undertake this part of the visit. The lack of clarity on documentation levels, as well as the necessity that both the physician and the APP work for the same organization, has caused to misunderstanding within healthcare institutions.

The growth of Medicare split/shared billing illustrates a dynamic interplay of legal changes, financial considerations, and the requirement for clarity in documentation and attribution. As CMS transitions to a time-based billing model, healthcare providers must change their billing procedures and ensure compliance.

Outsourcing to I-Conic Solutions Services appears to be a smart answer, providing knowledge in navigating the complexity of regulatory changes. A competent Professional Medical Billing Company specializes in adhering to the most recent requirements, assuring correct billing, and limiting the risk of noncompliance. By delegating billing functions to these experts, healthcare practitioners can streamline operations, improve efficiency, and focus on providing high-quality patient care. Outsourcing becomes a crucial ally in maintaining financial stability, enabling adaptability to changing rules, and eventually contributing to the healthcare industry’s continued growth.

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