In the evolving healthcare landscape, efficient billing practices are crucial for smooth operations and timely reimbursements. One such billing approach that has gained traction, particularly in physician groups and hospital settings, is split-share medical billing. If you are a healthcare provider or medical practice looking to maximize revenue and streamline billing operations, read the following vital information to better understand split-share medical billing.
What Is Split-Share Medical Billing and FS Modifier?
Split-share medical billing is a reimbursement approach that enables physicians and non-physician practitioners (NPPs) to collaboratively manage patient encounters, with both receiving appropriate compensation for their services. This billing model is particularly useful in settings like hospitals, outpatient clinics, and group practices, where both types of providers collaborate in patient care.
According to the Centers for Medicare & Medicaid Services (CMS), a split/shared visit involves a physician and an NPP from the same group performing parts of an Evaluation and Management (E&M) service in a facility setting. Payment is made to the practitioner who performs the substantive portion of the visit.
FS modifier: As of 1/1/2024, CMS is widely promoting the use of FS modifier. The new HCPCS Level II modifier FS Split (or shared) evaluation and management visit must be included on the claim to identify that the service was a split/shared visit for services furnished.
NPP*- Nurse practitioners, physician assistants, certified nurse midwives, and certified registered nurse anesthetists would all be considered NPPs.
What Is a Substantive Portion?
For a physician to bill a split/shared visit, the physician must perform a substantive portion of the encounter. The substantive portion refers to the Medical Decision Making (MDM) or when the physician spends more than 50% of the total visit time. Physician addendum to NPP’s note must clearly describe that a substantive portion was performed to bill under the physician’s name at 100%.
Split-Share Medical Billing Guidelines
Here are the guidelines for split-share medical billing
- Use the FS modifier when reporting split/shared visits to the charge of the provider doing more than 50% of the work.
- Applies to a physician working with an NPP.
- The physician and NPP should belong to the same billing group or practice. Examples: Thoracic surgery physicians and Thoracic surgery employed NPP can bill for a shared visit. However, thoracic surgery physicians and plastic surgery employed NPP cannot bill for a shared visit.
- Medical Faculty Group employed physicians and Hospital employed NPP cannot bill for a shared visit.
- Applicable exclusively to Evaluation and Management (E&M) services. Procedural services are excluded.
- The physician and NPP must personally assess the patient within the same day.
- The physician must perform a substantive portion of the encounter to be the billing provider.
- Documentation should identify contributions from both the physician and the NPP.
- The billing provider must sign and date the documentation.
- Combined physician and NPP documentation will determine the billable level of service.
- Split/shared visits are applicable solely in facility settings (Hospital Inpatient Units, Hospital Outpatient Departments, Hospital Observation Units, Hospital-based Skilled Nursing Facilities (SNFs), Critical Care Units (ICUs & CCUs)
- Split or shared services are not billable for these facility settings – Private Physician Offices or Clinics (non-facility settings); Independent Nursing Homes (not hospital-based SNFs); Standalone Urgent Care Centers (not affiliated with a hospital)
- Critical care services are eligible for split/shared billing based on time.
Medical Record Documentation is Essential
Ensuring compliance with CMS rules and accurate documentation can help healthcare providers minimize audit risks and optimize revenue streams. Documentation in the medical record must identify the physician and NPP who performed the visit. In addition, the individual who performed the substantive portion of the visit (and therefore billing for the visit) must sign and date the medical record.
Examples of appropriate attestations:
“I provided a substantive portion of the care of this patient. I personally performed the ______________ for this encounter.” (Insert history, exam, or MDM.)
“I provided a substantive portion of the care of this patient. I personally performed the ______________ for this encounter.” (Insert history, exam, or MDM, followed by documentation of the history, exam, or MDM to the extent needed to support the assigned E/M code.)
“I provided a substantive portion of the care of this patient. I personally provided more than half of the total time dedicated to the treatment of this patient.”
Advantages of Split-Share Medical Billing
One key advantage is enhanced provider collaboration. By allowing physicians and NPPs to share a patient encounter, hospitals and group practices can streamline workflows and optimize resource allocation. This results in better patient access, as multiple providers can contribute to patient management, reducing waiting time and ensuring timely care.
From a financial standpoint, split/shared billing helps maximize reimbursements. When the physician performs the substantive portion of the visit, the service can be billed at 100% of the physician’s rate rather than the lower NPP reimbursement rate. This ensures that hospitals and healthcare facilities are appropriately compensated for services while maintaining regulatory compliance.
Additionally, split/shared billing supports operational efficiency by leveraging NPPs to handle routine patient care while physicians focus on complex decision-making. This division of responsibilities improves overall provider productivity and reduces burnout.
Shortcomings of Split-Share Medical Billing
While split-share billing offers many benefits, there are some challenges and limitations to consider:
Documentation challenges – Properly documenting split-share encounters requires detailed record-keeping to demonstrate compliance with CMS guidelines. Both providers must clearly indicate their contributions to the visit.
Reimbursement confusion – Understanding whether a visit qualifies for billing under a physician or an NPP can be complex, especially with evolving CMS guidelines.
Essential Medical Record Documentation
Documentation in the medical record must identify the physician and NPP who performed the visit. In addition, the individual who performed the substantive portion of the visit (and therefore billing for the visit) must sign and date the medical record.
Examples of appropriate attestations:
“I provided a substantive portion of the care of this patient. I personally performed the ______________ for this encounter.” (Insert history, exam, or MDM.)
“I provided a substantive portion of the care of this patient. I personally performed the ______________ for this encounter.” (Insert history, exam, or MDM, followed by documentation of the history, exam, or MDM to the extent needed to support the assigned E/M code.)
“I provided a substantive portion of the care of this patient. I personally provided more than half of the total time dedicated to the treatment of this patient.”
Risk of targeted probe—Since split/shared billing involves multiple practitioners contributing to the same patient visit, it increases the need for accurate documentation to avoid billing discrepancies. Medicare and private insurers use targeted probes to investigate irregularities in claims, often focusing on high-risk billing areas such as split/shared visits. Incorrect application of split/shared billing guidelines can trigger audits, leading to delayed reimbursements, denials, or penalties.
2025 Guideline Update
The 2025 guidelines provide further clarification on what constitutes the ‘substantive portion’ of an E&M service.
- The first set pertains to time as the driver of the service code. The practitioner who spends the majority of the total encounter time on the service date is responsible for reporting the service for reimbursement.
- The second involves medical decision-making (MDM) as the driver of the service code. The provider who finalizes the care plan and assumes responsibility for managing associated risks is considered to have provided the substantive portion of the visit. If MDM is used to assign the level of service, only the person who performs an independent interpretation or discussion of management or test interpretation may use those categories.
How PracticeForces Can Help
Split-share medical billing is an effective way for healthcare providers to improve patient access, maximize reimbursements, and optimize workflow. However, understanding and implementing the process correctly is crucial to avoid compliance risks. By partnering with a trusted medical billing expert like PracticeForces, your practice can navigate these complexities with confidence and efficiency. For more information on optimizing your billing processes, contact PracticeForces today!
