For Calendar Year 2024 Centers for Medicare and Medicaid (CMS) has finalized the definition for “substantive portion” as it pertains to Split Shared E/M Visits. For billing purposes “substantive portion” means more than half of the total time spent by the physician or nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making. This means “Medicare will allow time or medical decision making to serve as the substantive portion of a split (or shared) visit. Payment is made to the practitioner who performs the substantive portion of the visit.
Split (or shared) E/M visits refer to visits provided in part by physicians and in part by other nonphysician practitioners in hospitals and other institutional settings including skilled nursing facility (SNF). For CY 2024, the revision for the definition of “substantive portion” of a split (or shared) visit is to include the revisions to the Current Procedural Terminology (CPT) guidelines, such that for Medicare billing purposes, the “substantive portion” means more than half of the total time spent by the physician or nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical substantive portion of a split (or shared) visit. Additionally, CMS requires that the documentation must identify the two individuals who performed the service and the billing professional sign and date the record.
Layman terms: CMS will allow the substantive portion to be determined based on the practitioner who spent more than 50% of the time or the practitioner who performs and approves the medical decision-making (MDM). When time is used, time spent with the patient jointly by both practitioners can only be counted once.
Applies to Provider Types: MD, DO, PA, and NP
Location: Place of service 19 Off campus outpatient hospitals or 22 On campus outpatient hospitals. For outpatient offices, only incident of billing is allowed.
Example: If the NPP first spent 7 minutes with the patient and the physician then spent another 10 minutes, their individual time spent would be summed to equal a total time of 17 minutes. The physician would bill for this visit since they spent more than half of the total time (10 of 17 total minutes). If, in the same situation, the physician and NPP met together for eight additional minutes (beyond the 17 minutes) to discuss the patient’s 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 25 minutes, and the physician would bill for the visit since they spent more than half of the total time (18 of 25 total minutes).
To bill as a split or shared subsequent hospital service, the billing practitioner reports CPT code 99231 if basing the coding on time. For calendar year 2024, if not using time, bill CPT codes 99231–99233 as meets the key component level on which the coding is based – the billing practitioner must perform and document medical decision making.
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.
- Teaching that is general and not limited to discussion that is required for the management of a specific patient.
Stay tuned to for additional updates on these impending changes taking effect on January 1, 2024. For assistance with preparing your practice for this change do not hesitate to reach out to us directly. At Neolytix, we are always ready to assist your practice with medical billing, coding, and revenue cycle management.
Our medical billing services are 100% HIPAA-compliant and provided by a certified team of professionals. Likewise, our medical credentialing services are fast, efficient, and organized according to rigorous workflow management procedures.