You’ll find Medicare's new and revised rules for hospital visits, nursing facility visits, prolonged services and split/shared visits in
CMS 100-04, Change Request 13064, released February 9. The update includes more information on documenting time-based visits but is silent on component-based split/shared billing.
The change request updates
Internet-only Manual 100-04, chapter 12, §30.6 with the new and revised E/M rules that were released in the final 2023 Medicare physician fee schedule. The update codifies the CPT overhaul of level-based E/M visits, such as the addition of observation visits to inpatient hospital codes (
99221-99223, 99231-99233 and
99238-99239), and is effective Jan. 1. However, Medicare administrative contractors (MAC) have until May 9 to implement the changes.
In addition to making several expected changes the update also sheds a little light on the documentation requirements for time-based visits. The language will be added to section 30.6.7:
Our reviewers will use the medical record documentation to objectively determine the medical necessity of the visit and accuracy of the documentation of the time spent (whether documented via a start/stop time or documentation of total time) if time is relied upon to support the E/M visit.
Remind providers they need to document what they did on the date of the face-to-face encounter in addition to the total time.
Medicare clarified language for long-standing guidance such as how to report two hospital visits on the same day. However, Medicare did not clear up the current split/shared mystery surrounding the documentation it expects when practices base split/shared billing on the history or exam portions of an encounter.
Here’s a sample of the new language added to section 30.6.18(B) (emphasis added):
In other words, for calendar year 2023, the practitioner who spends more than half of the total time, or performs the medically appropriate history or exam described in the code descriptor, or MDM can be considered to have performed the substantive portion and can bill for the split (or shared) E/M visit.
The reference to the code is puzzling because the descriptors state “which requires a medically appropriate history and/or examination.” Unless Medicare or individual MACs release more guidance individual auditors could decide whether a history or an exam represented the substantive portion of the visit. However, practices can use medical decision-making or time for split/shared visits.