“Substantive Portion”: An update on billing appropriately for split/shared evaluation and management (E/M) visits

By Courtney Zydron, MD, MBA
VACEP Secretary & President, Williamsburg Emergency Physicians Inc.

What’s the issue? Emergency Physicians who supervise Physician Assistants and Nurse Practitioners need to be aware of the 2024 CMS “Split/Shared Services” guideline in order to receive appropriate compensation for their services. This guideline dictates how physician led “team-based care” is reimbursed for a single E/M code.

What’s the change? As of Jan. 1, 2024, in order for the E/M to be reimbursed at the physician rate, there has to be clear documentation of the physician performing the “substantiative part of the Medical Decision Making (MDM).”  This changes the prior standard of documenting discrete elements from the History of Present Illness (HPI), PE and MDM to obtain credit for shared services. This aligns with the CMS changes in documentation released in 2023 for Emergency Medicine E/M Codes. The update is being implemented August 1.

Zydron

What does this mean for Emergency Physicians? All Emergency Physicians participating in team-based care need to take notice of the new documentation requirements to appropriately bill for services and to defend their coding in the event of an audit. 

How are split/shared services defined? Team-based care qualifying as a split/shared visit by CMS means “physician(s) and other QHP(s) may act as a team in providing care for the patient, working together during a single E/M service.” This rule does not apply to physician documentation when working with a resident or medical student.

Performing a “substantive portion of the MDM” per CPT is when a Physician performs 2 of the 3 elements of the decision making:

·       Number and Complexity of Problems Addressed (COPA) at the encounter

·       Amount and Complexity of Data to be reviewed and analyzed

·       Risk of Complications and/or morbidity or mortality of patient management

For critical care codes, which require an element of time for billing, the “substantive portion” means the physician spent more than 50% of the time performing the service. This must be clearly documented to bill under the physician critical care codes.

Deeper analysis: To reduce ambiguity during a payer audit and provide additional clarity, it is recommended that a physician includes a clear statement in the attestation to mirror the CMS guidelines. This should include terms such as “substantiative portion of the medical decision making,” and statements such as “personally developed, reviewed and/or approved plan of care as documented by the QHP.” 

• When billing under a shared services model, the physician is taking “responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management.” 

• Additional documentation to support billing under the physician includes providing a summary of the complex decision-making, referencing clinical findings and diagnostics, conversations with consultants, and post-disposition plan of care.

• If the team is using the interpretation of diagnostic studies including EKG and imaging to support the complexity of MDM, these should be documented by the physician to avoid downcoding. 

A final word: Awareness of these guidelines and effectively documenting the physician’s involvement in a shared services encounter can have significant revenue impact, especially with government payors that reimburse 15% less for codes billed under the APP. As payor audits are returning post-pandemic, it is important to document clearly to avoid future issues with ambiguous documentation.

Get the new guidelines

Be sure to review the new guidelines and ensure your group or billing team is aware of the latest update to document split visits and bill in accordance with state and federal law. You can find the change request here in a PDF link.