Shared Services

The American Medical Association (AMA) has revised the CPT guidelines regarding "split or shared visits" for 2024. The definition of a "split or shared visit" now refers to the substantive portion of an Evaluation and Management (E/M) service. The revised definition states that the substantive portion is determined either by more than half of the total time spent by the physician and other qualified healthcare professional (QHP) performing the split visit or by a substantive part of the medical decision making (MDM). These guidelines are intended to assist in determining which healthcare provider, the physician or QHP, may bill for the service.

Physician(s) and other qualified health care professional(s) (QHP[s]) may act as a team in providing care for the patient, working together during a single E/M service. The split or shared visits guidelines are applied to determine which professional may report the service. If the physician or other QHP performs a substantive portion of the encounter, the physician or other QHP may report the service.

For the purpose of reporting E/M services within the context of team-based care, performance of a substantive part of the MDM requires that the physician(s) or other QHP(s) made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management. By doing so, a physician or other QHP has performed two of the three elements used in the selection of the code level based on MDM.

If the amount and/or complexity of data to be reviewed and analyzed is used by the physician or other QHP to determine the reported code level, assessing an independent historian’s narrative and the ordering or review of tests or documents do not have to be personally performed by the physician or other QHP, because the relevant items would be considered in formulating the management plan.

Independent interpretation of tests and discussion of management plan or test interpretation must be personally performed by the physician or other QHP if these are used to determine the reported code level by the physician or other QHP.

Recognizing that facility-based services have evolved to a more team-based approach to care, CMS believes that when an E/M service is shared between a physician and a PA/NP (which CMS refers to as nonphysician practitioner or NPP) in the same group, there is close coordination and an element of collaboration in providing care to the beneficiary. In 2022, revisions were made to Chapter 12 Section 30.6.18 of the Medicare Claims Processing Manual to coding and documentation for split/shared visits.

Definition of Split (or Shared) Visit - A split (or shared) visit is an evaluation and management (E/M) visit in the facility setting that is performed in part by both a physician and a nonphysician practitioner (NPP) who are in the same group, in accordance with applicable law and regulations such that the service could be billed by either the physician or NPP if furnished independently by only one of them. Payment is made to the practitioner who performs the substantive portion of the visit.

Facility setting means an institutional setting in which payment for services and supplies furnished incident to a physician or practitioner’s professional services is prohibited under our regulations.

As the CMS definition indicates, the ED physician and PA/NP must be part of the same group to report a split/shared visit.  As there are many varied circumstances under which ED physicians and PAs or NPs interact and the stipulation for "same group practice" may be open to interpretation, you are advised to seek legal counsel related to different group structures’ final instructions on billing when shared services arise. In addition, some non-Medicare payers still do not recognize PAs or NPs, so the service may have to be reported using the physician’s NPI.

The CY 2024 Final Rule indicated that CMS would be adopting the CPT definition of substantive portion for 2024.

In consideration of the changes made by the CPT Editorial Panel, we are revising our definition of “substantive portion” of a split (or shared) visit to reflect the revisions to the CPT E/M guidelines. Specifically, for CY 2024, for purposes of Medicare billing for split (or shared) services, the definition of “substantive portion” means more than half of the total time spent by the physician and NPP performing the split (or shared) visit, or a substantive part of the medical decision-making as defined by CPT.

• Page 476 CY 2024 Final Rule

The primary documentation concern is that the medical record is clinically appropriate and accurately reflects the patient’s condition and services rendered in the ED; the combined documentation from the ED physician and PA/NP should support the E/M code assigned.

CMS policy stipulates that the documentation in the medical record must identify the individual practitioners who performed the visit. The practitioners who performed the substantive portion will bill for the visit and must sign and date the medical record.

In cases where the encounter is split/shared between the ED physician and the PA/NP, it is necessary for at least one of the practitioners to have face-to-face contact with the patient. However, it does not necessarily have to be the practitioner who performs the substantive portion of the visit and bills for it.

CPT guidelines do not explicitly outline specific documentation requirements; however, they do specify that the physician/QHP who developed or approved the patient's management plan and assumes responsibility for its implementation, along with its inherent risks, should be considered as having performed the substantive part of the MDM. Therefore, the ED physician's documentation should indicate their approval of the management plan and acceptance of responsibility for the patient's treatment.

Additionally, if the assignment of an E/M code relies on Data Category 2 (independent interpretation) and/or Data Category 3 (discussion with an external physician), the documentation should indicate that these MDM elements were performed by the ED physician.

In the Federal Register for CY 2020, CMS established a general principle to allow the physician/QHP who furnishes and bills for professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team. The scope of this principle was stated to encompass all Medicare-covered services that are reimbursed under the physician fee schedule.

In accordance with this existing principle, it is not required for the ED physician to document the MDM. Instead, they may review and approve the PA/NP documentation and attest to their performance of the substantive portion of the MDM. For instance, the physician may state:

• "I personally made/approved the management plan for this patient and take responsibility for the patient management."

If the assignment of the E/M code relies on Data Category 2 (independent interpretation) and/or Data Category 3 (discussion with an external physician), the ED physician's documentation should include documentation of their independent interpretation and/or reference to any discussions the ED physician had with external physicians or other sources. In these circumstances, the attestation might also include the independent interpretation or discussion of management. For example:

• “I personally made/approved the management plan for this patient and take responsibility for the patient management. I independently interpreted the EKG, which showed NSR with No ST changes.”

or

• “I personally made/approved the management plan for this patient and take responsibility for the patient management. I discussed the patient with cardiology. They recommend cardioversion in the ED and follow-up with their office.

If the ED physician documents the MDM elements they performed during the encounter, e.g., plan of care, interpretations, medications prescribed, discharge instructions, etc., they are not required to additionally document an attestation. The attestation example provided in Question 6 serves as an alternative to the ED physician having to re-document the plan of care or MDM elements that have already been documented by the PA/NP.

Critical care services may be provided by a qualified PA/NP and reported for payment under the PA/NP National Provider Identifier (NPI) when the services meet the definition and requirements of critical care services. The provision of critical care services must be within the scope of practice and licensure requirements for the State where the qualified PA or NP practices and provides the service(s). As critical care is a time-based service, the PA/NP must document the total time (not necessarily start and stop times) spent providing critical care services.

As of January 1, 2022, CMS policy allows critical care visits to be furnished as a split/shared visit. The substantive portion for critical care services is defined as more than half of the total combined time spent by an ED physician and PA/NP in the same group. Consistent with all split/shared visits, when two or more practitioners spend time jointly meeting with or discussing the patient as part of a critical care service, the time can be counted only once for purposes of reporting the split (or shared) critical care visit.

For coding, critical care time provided by the ED physician and PA/NP on a given calendar date is summed. The practitioner who furnishes the substantive portion of the cumulative critical care time reports the critical care service with the appropriate combination of 99291 and 99292. See the ACEP Critical Care FAQ for more information about assigning 99291/99292.

Individual state licensing regulations and hospital medical staff policies and procedures govern the physician's requirement to provide supervision of the PA/NP. Additionally, different payers may interpret the definition of supervision differently.

Services Medicare covers as "incident to" are services furnished in a physician’s office. "Incident to" is a Medicare reimbursement policy whereby, under certain circumstances, the physician can bill and be paid for services provided by staff members employed by the physician. "Incident to" is not applicable in the hospital setting, inpatient or outpatient, and as such, is not applicable in the emergency department. 

The shared service concept only applies to E/M services, and "incident to" does not apply in the ED. Therefore, procedures and interpretations the PA/NP performs for Medicare patients must be billed using the PA/NPs NPI number.  The carrier will pay any physician or PA/NP authorized to bill Medicare services at the appropriate physician fee schedule amount based on the rendering NPI.

As the "incident to" rules are a CMS construct, the ED physician billing for PA/NP procedures for non-Medicare patients may depend on internal hospital or ED group policy and/or contractual agreements with commercial payers.

Yes, all 50 states give PAs/NPs prescribing authority and have enacted fairly detailed statutes and regulations that define physician assistants and nurse practitioners, describe their scope of practice, discuss supervision, designate the agency that will administer the law, set application and renewal criteria, and establish disciplinary measures for specified violations of the law. The actual language in the scope of practice section of the regulations is generally broad, allowing PAs/NPs to perform those services within the scope of the supervising physician if delegated by the physician and within the education and training of the PA/NP.

Unlike Medicare, which mandates coverage of services provided by a PA/NP, each state determines whether a PA/NP is an eligible provider under its respective Medicaid program.  All states and the District of Columbia cover PAs or NPs in the Medicaid fee-for-service or managed care plans at the same or lower rate as that paid to physicians. There are differences, however, in how states ask PAs or NPs to identify themselves as a provider of service.  In some states, medical services provided by PAs or NPs are billed under the physician's name, while in other states, PAs or NPs use a modifier code to identify their services. Finally, some state Medicaid programs will limit procedure reimbursement even when the state recognizes the procedure as within the APP's scope of service. Check with your state Medicaid carrier for specific policies and procedures.

Yes. If the PA/NP will be providing services to Medicare patients, and you want to bill for such services, Medicare mandates that the PA/NP have an NPI number. It would be wise to do a compliance audit with your company or billing entity to ensure that correct NPI numbers are on the CMS1500 for services provided by the PA/NP.

In the past, Medicare required modifiers such as "AN" or "AS" to identify services performed by a PA or NP. However, Medicare carriers have abandoned modifiers for independent services provided by a PA/NP and now require they obtain and use their NPI to identify themselves on claims.

Modifier -FS modifier must be attached to any E/M code for services provided as a Split/Shared Visit, regardless of whether the physician or PA/NP provided the substantive portion or bills for the visit.

Yes, but be careful. A scribe records the findings of a physician. If the PA/NP independently obtains the history and performs a physical exam, a third-party payer might not consider this a scribe function but rather an independent service component by a healthcare provider, hence subject to the payer's relevant payment policies.

Medicare-managed care plans are governed by a combination of federal regulations,  state law and private contracts with varying details regarding split/shared billing.

Medicare will pay for any service performed by a PA/NP, provided the service is medically necessary and within the PA/NP scope of practice in the state where they practice.

The American Academy of Physician Assistants (AAPA) can be reached at the address below. This website contains a wealth of information. Access the government and practice issues section and click on reimbursement for additional documentation.

The American Academy of Physician Assistants (AAPA)
2318 Mill Road, Suite 1300
Alexandria, Virginia 22314-1552
Phone: 703-836-2272
Fax: 703-684-1924

The American College of Nurse Practitioners (ACNP)
AANP National Administrative Office
PO Box 12846 
Austin, Texas 78711
Phone: 512-442-4262
Fax: 512-442-6469