AMA Q&A session reveals substantive confusion over split/shared guidelines

by: Julia Kyles, CPC Nov 17, 2022

Make sure billers, coders, clinicians and compliance staff understand that the substantive portion rule does not apply to CPT split/shared coding guidelines. Barbara Levy, M.D., AMA CPT Editorial Panel Member, took questions on the CPT E/M update on day two of the 2023 CPT and RBRVS Symposium.

A few attendees had questions about the substantive portion for a split/shared visit. But there was a problem: Substantive portion is a Medicare-specific rule that went into effect Jan. 1, 2022. It determines if the physician or qualified health care professional (QHP) bills for a CMS split/shared service. It isn’t mentioned in the CPT E/M guidelines for split/shared coding.

Help staff find their way between the two versions of split/shared with this summary.

CPT split/shared

CPT split/shared applies to office/other outpatient services (99202-99205 and 99212-99215). It will apply to all level-based visits except emergency department services (99281-99285) effective Jan. 1, 2023.
The physician and QHP document time spent on relevant activities listed in the CPT guidelines on the date of the encounter.
The coder selects a code based on the total time documented by both providers.
Only an option for time-based coding.

CMS split/shared

Applies to level-based facility E/M services and critical care. Does not apply to office/other outpatient visits.
The visit is billed under the name and national provider identifier of the provider who performed the substantive portion of the encounter.
The substantive portion is more than 50% of time for the encounter. Performance of at least one key component for the encounter will also be an option until Jan. 1, 2024.
The biller should add modifier FS (Split [or shared] evaluation and management visit) to the claim.

Editor’s note: The summary is based on a slide from the upcoming presentation 2023 Kickoff: CPT and Physician Fee Schedule Update. The presentation will take place during the 2022 Advanced Specialty Coding, Compliance & Reimbursement Symposium, Dec. 5-7, Dallas.

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Blog Tags: AMA, CMS, E/M services

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