(Medicare Claims Processing Manual)

During the transitional year from January 1, 2023 through December 31, 2023, except for critical care visits, the substantive portion can be one of the three key E/M visit components (a medically appropriate history or exam, or medical decision- making (MDM )), or more than half of the total time spent by the physician and NPP performing the split (or shared) visit.  In other words, for calendar year 2023, the practitioner who spends more than half of the total time, or performs the medically appropriate hist ory 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.  When one of the three key components is used as the substantive portion in 2023, the practit ioner who bills the visit must perform that component in its entirety in order to bill.  For example, if history is used as the substantive portion, the billing practitioner must perform the history as described in the code descriptor in order to bill.  If  physical exam is used as the substantive portion, the billing practitioner must perform the exam as described in the code descriptor in order to bill.  If MDM is used as the substantive portion, each practitioner could perform certain aspects of MDM, but the billing practitioner must perform all portions or aspects of MDM that are required to select the visit level billed.   For critical care visits, starting for services furnished in CY 2022, the substantive portion will be more than half of the total time.  A unique listing of qualifying activities for purposes of determining the substantive portion of critical care visits a pplies (see below).   We summarize these policies in the following table.   Definition of Substantive Portion for E/M Visit Code Families   E/M Visit Code Family  2022 -2023 Definition of Substantive Portion  2024 Definition of Substantive Portion  Other Outpatient*  History, or exam, or MDM, or more than half of total time  More than half of total time  Inpatient/Observation/Hospital/SNF*  History, or exam, or MDM, or more than half of total time  More than half of total time  Emergency Department  History, or exam, or MDM, or more than half of total time  More than half of total time  Critical Care  More than half of total time  More than half of total time  Acronyms: E/M (Evaluation and Management), MDM (medical decision- making), SNF (Skilled Nursing Facility)  *Office visits and Nursing Facility visits are not billable as split (or shared) services.   (2) Distinct Time   In accordance with the CPT E/M Guidelines, only distinct time can be counted.  When the practitioners jointly meet with or discuss the patient, only the time of one of the practitioners can be counted.   Example: I f the NPP first spent 10 minutes with the patient and the physician then spent another 15 minutes, their individual time spent would be summed to equal a total of 25 minutes. The physician would bill for this visit, since they spent more than half of the total time (15 of 25 total minutes).  If, in the same situation, the physician and NPP met together for five additional minutes (beyond the 25 minutes) to discuss the patients treatment plan, that overlapping time could only be counted once for purposes of establishing total time and who provided the substantive portion of the visit.  The total time would be 30 minutes, and the physician would bill for the visit, since  they spent more than half of the total time (20 of 30 total minutes).    (3) Qualifying Time   Drawing on the  CPT E/M Guidelines, except for critical care visits, the following listing of activities can be counted toward total time for purposes of determining the substantive portion, when performed and whether or not the activities involve direct patient contact:    Preparing to see the patient (for example, review of tests).   Obtaining and/or reviewing separately obtained history.  Performing a medically appropriate examination and/or evaluation.   Counseling and educating the patient/family/caregiver.  Ordering medications, tests, or procedures.   Referring and communicating with other health care professionals (when not separately reported).   Documenting clinical information in the electronic or other health record.   Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.   Care coordination (not separately reported).   Practitioners cannot count time spent on the following:    The performance of other services that are reported separately.   Travel.   Teaching that is general and not limited to discussion that is required for the management of a specific patient.   See section 30.6.12 for a listing of qualifying activities for purposes of determining the substantive portion of critical care services.   For all split (or shared) visits, one of the practitioners must have face -to-face (in -person) contact with the patient, but it does not necessarily have to be the physician, nor the practitioner who performs the substantive portion and bills for the visit.  The substantive portion can be entirely with or without direct patient contact, and is determined by the proportion of total time, not whether the time involves patient contact.    (4) Application to Prolonged Services   For 2022 and 2023 transitional years, the billing practitioner reports the codes for the primary service and the prolonged services, regardless of the amount of time the billing practitioner spent.  Starting in 2024, since the substantive portion is more than half of the practitioners total time, the physician or practitioner who spent more than half the total time (the substantive portion starting in 2024) will bill for the primary E/M visit and the  prolonged service code(s) when the service is furnished as a split (or shared) visit, if all other requirements to bill for split (or shared) services are met. The physician and NPP will add their time together, and whomever furnished more than half of the total time, including prolonged time, (that is, the substantive portion) will report both the primary service code and the prolonged services add- on code(s), assuming the time threshold for reporting prolonged services is met (see Prolonged Services section above).    During the transitional calendar years 2022- 2023, when practitioners use a key component as the substantive portion, Emergency department and critical care visits are not reported as prolonged services.    We summarize these policies in the following table.   Reporting Prolonged Services for Split (or Shared) Visits   E/M Visit Code Family  2022 -2023  2024  If Substantive Portion is a Key Component  If Substantive Portion is Time  Substantive Portion Must Be Time Other Outpatient*  Combined time of both practitioners must meet the threshold for reporting prolonged services  Combined time of both practitioners must meet the threshold for reporting prolonged services  Combined time of both practitioners must meet the threshold for reporting prolonged services  Inpatient/Observation/Hospital/SNF*  Combined time of both practitioners must meet the threshold for reporting prolonged services  Combined time of both practitioners must meet the threshold for reporting prolonged services  Combined time of both practitioners must meet the threshold for reporting prolonged services  Emergency Department  N/A N/A N/A Critical Care  N/A N/A N/A Acronyms: E/M (Evaluation and Management); SNF (Skilled Nursing Facility)  *Office visits and Nursing Facility visits are not billable as split (or shared) services.   C. New and Established Patients, and Initial and Subsequent Visits   Split (or shared) visits may be billed for new and established patients , as well as for initial and subsequent visits, that otherwise meet the requirements for split (or shared) visit payment.  D. Settings of Care   Split (or shared) visits are furnished only in the facility setting, meaning institutional settings in which payment for services and supplies furnished incident to a physician or practitioners professional services is prohibited under our regulations at 42 CFR  410.26.    Accordingly, split (or shared) visits are billable for E/M visits furnished in hospital and skilled nursing facility (SNF) settings. Visits in these settings that are required by our regulations to be performed in their entirety by a physician are not bill able as split (or shared) services. For example, our Conditions of Participation require certain SNF visits to be performed directly and solely by a physician; accordingly, those SNF visits cannot be billed as a split (or shared) visit (see Section 30.6.13).   E.  Medical Record Documentation   Documentation in the medical record must identify the physician and NPP who performed the visit.  The individual who performed the substantive portion of the visit (and therefore bills for the visit) must sign and date the medical record.   F. Claim Identification   Modifier -FS (Split or Shared E/M Visit) must be reported on claims for split (or shared) visits, to identify that the service was a split (or shared) visit.    The modifier identified by CPT for purposes of reporting partial services (modifier - 52 (reduced services)) cannot be used to report partial E/M visits, including any partial services furnished as split (or shared) visits. Medicare does not pay for partial  E/M visits.     30.6.19  Office/Outpatient Evaluation and Management  (O/O E/M) Complexity Add- on Paymen t (Code G2211)  (Rev. 12370; Issued: 11- 21-23; Effective: 01 -01-24; Implementation: 01 -02-24)  Starting on January 1, 2024 O/O E/M visit complexity add- on code, G2211 to describe intensity and complexity inherent to O/O E/M visits not accounted for in the valuation of the primary service codes is unbundled and separately payable as an additional payment to the payment for O/O E/M visit primary service codes (99202- 99205, 99211- 99215).   The full descriptor, refined in the calendar year (CY) 2021 PFS final rule, is code G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. (Add -on code, list separately in addition to office/outpatient evaluation and management visit, new or established )). (See the CY 2021 Medicare Physician Fee Schedule final rule in the Federal Register (85 FR 84571)).   The A/B MACs (A & B) shall not pay code G2211 on the same date of service as an office/outpatient evaluation and management visit (codes 99202- 99205, 99211- 99215) reported with Modifier 25, to the same beneficiary by the same practitioner or nonphysician practitioner.    40 - Surgeons and Global Surgery  (Rev. 1, 10- 01-03) B3-4820  A national definition of a global surgical package has been established to ensure that payment is made consistently for the same services across all A/B MAC (B) jurisdictions, thus preventing Medicare payments for services that are more or less comprehensi ve than intended.  The national global surgery policy became effective for surgeries performed on and after January 1, 1992.  The instructions that follow describe the components of a global surgical package and payment rules for minor surgeries, endoscopies and global surgical packages that are split between two or more physicians.  In addition, billing, mandatory edits, claims review, adjudication, and postpayment instructions are included.  In addition to the global policy, uniform payment policies and claims processing requirements have been established for other surgical issues, including bilateral and multiple surgeries, co-surgeons, and team surgeries. 40.1 - Definition of a Global Surgical Package  (Rev . 11287; Issued:03- 02-22; Effective:01 -01-22; Implementation: 02 -22-22)  B3-4821, B3- 15900.2  Field 16 of the Medicare Fee Schedule Data Base (MFSDB) provides the postoperative periods that apply to each surgical procedure.  The payment rules for surgical procedures apply to codes with entries of 000, 010, 090, and, sometimes, YYY.  Codes with 090 in Field 16 are major surgeries.  Codes with 000 or 010 are either minor surgical procedures or endoscopies. Codes with YYY are A/B MAC (B) -priced codes, for which A/B MACs (B) determine the global period (the global period for these codes will be 0, 10, or 90 days).  Note that not all A/B MAC (B) -priced codes have a YYY global surgical indicator; sometimes t he global period is specified.  While codes with ZZZ are surgical codes, they are add -on codes that are always billed with another service.  There is no postoperative work included in the fee schedule payment for the ZZZ codes.  Payment is made for both the primary and the add- on cod es, and the global period assigned is applied to the primary code.   A. Components of a Global Surgical Package  B3-15011, B3- 4820- 4831