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

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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