The Ambiguities of Split/Shared Visits

The new CPT® books are out, and they include a discussion about shared visits. Pamela Schulman (a Monitor Mondays listener) asked a great question: “How does this language interact with Medicare’s shared visit regulation?”

The answer is that to some extent, it doesn’t. 

I have to admit to a bit of uncertainty here. In the old days, there was a regulation that explicitly incorporated CPT into the Medicare rules. In recent years, I have been unable to find it. I think it is gone, but I haven’t encountered a situation requiring an exhaustive search, so I could be wrong.

Here is a look at the language: 

Physician(s) and other qualified healthcare professional(s) (QHPs) may act as a team in providing care for the patient, working together during a single E&M (evaluation and management) service.  The split or shared guidelines are applied to determine which professional may report the service. If the physician or other QHP performs a substantive portion of the encounter, the physician or other QHP may report the service. If code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service. For the purpose of reporting E&M services within the context of team-based care, performance of a substantive part of the MDM (medical decision-making) requires that the physician(s) or other QHP(s) made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan, with its inherent risk of complications and/or morbidity or mortality of patient management. By doing so, a physician or other QHP has performed two of the three elements used in the selection of the code level based on MDM. If the amount and/or complexity of data to be reviewed and analyzed is used by the physician or other QHP to determine the reported code level, assessing an independent historian’s narrative and the ordering or review of tests or documents do not have to be personally performed by the physician or other QHP because the relevant items would be considered in formulating the management plan. Independent interpretation of tests and discussion of management plan or test interpretation must be personally performed by the physician or other QHP if these are used to determine the reported code level by the physician or other QHP.

That isn’t the clearest paragraph.

But regardless of the content of CPT, I do feel comfortable stating that when there are specific Medicare regulations on a topic, they will supersede any guidance in the CPT. There is a federal regulation addressing shared visits, found at 42 C.F.R. § 415.150. It defines a split or shared visit as “an evaluation and management visit in the facility setting that is performed in part by both a physician and a non-physician practitioner who are in the same group.”

The regulations define a facility as “an institutional setting in which payment for services and supplies furnished incident to a physician’s services is prohibited.” That definition is very, very different from what appears in CPT.

CPT uses the term “split or shared visits” in the way I would expect it to be conventionally understood by normal humans: a shared visit is when two professionals see the patient at the same visit. While Medicare limits the term to facilities such as hospitals and skilled nursing facilities, the CPT language isn’t as narrow and applies to office visits in a site of service 11.

Candidly, I am a bit disappointed in the new CPT, because I think it muddies what has historically been clear waters. I don’t believe that CPT has ever discussed incident-to-services, so I don’t know why it suddenly feels compelled to mention visits by two professionals, which are really a subset of what I would call services “incident to” a physician.

The CPT shared visit language claims to establish a principle that the professional who spends the most time with the patient must bill if the bill is based on time. To me, it should always be permissible to bill under whatever professional you wish, as long as the claim accurately states the services provided by that professional.

But here is the key point. 

When you are dealing with Medicare claims, focus on the Medicare regulations. CPT will be more important in situations where Medicare is silent on an issue or for claims submitted to private payors. But even when you are dealing with private payors, if you have a contract with the plan, and that contract incorporates the plan’s policy manuals, those will take precedence over CPT. 

The bottom line is that the new language has no impact on Medicare claims. I suppose it could have an impact on some private payer patients, and no, I do not think there is anything terribly shocking or revolutionary in the relevant paragraph. 

I would argue that the new CPT language should not have a material impact on most coding and billing practices.