Billing for Split or Shared Services Must Account for Medical Decision Making in Addition to Time

September 13, 2022

The American Society of Clinical Oncology (ASCO) issued a new position statement on Medicare billing for split or shared (split/shared) evaluation and management (E/M) services. The statement summarizes ASCO’s concerns about changes to split/shared E/M services and makes recommendations to better align Medicare coding for E/M services with the care that beneficiaries with cancer need.

Split/shared services are E/M services performed jointly between a physician and an advanced practice provider (APP) in the same group, in a facility setting. In the 2022 Medicare Physician Fee Schedule (PFS) final rule, the Centers for Medicare & Medicaid Services (CMS) codified the definition of split/shared E/M visits, determining that such visits should be only be billed by the physician or practitioner who provides the “substantive portion” of the visit.

Beginning in 2022 and 2023, CMS allowed the “substantive portion” of the visit to be determined by either medical decision making, time spent with the patient, or completion of other significant components of the E/M visit. However, starting January 1, 2024, CMS will base the determination of the “substantive portion” of the split/shared visit entirely on time spent, meaning that patient care for split/shared services will be billed by the practitioner who spends more than half of the of the visit with the patient, without regard to the need for clinical decision making.

ASCO agrees with policymakers about the need to promote and strengthen team-based cancer care, but the society is concerned that this change to the definition of split/shared E/M visits may lead to a significant misalignment of clinical resources, including a potential limitation on the use of APPs in clinical practice. This policy may also result in lost productivity and efficiency, difficulty maintaining care quality and patient safety, and heightened financial pressure that may increase practice consolidation.

ASCO recommends the following to promote team-based care and accurate coding and billing:

  • CMS should propose an alternative policy in the 2023 PFS final rule that allows physicians or APPs to bill split/shared visits based on either time or medical decision making.
  • CMS should work with specialties to ensure a smooth transition to updated billing practices and adequate and appropriate reimbursement. Current policy will require education and significant changes to day-to-day workflow.
  • CMS should work with stakeholders to ensure that resources are allocated in a manner that: emphasizes team-based, evidence-supported care; reimburses physicians at adequate rates; and implements future reforms in a way that reduces administrative burdens for patients and health care professionals.
  • Congress should work with the physician community and other stakeholders to develop solutions to systematic problems that discourage team-based approaches to care in both public and private systems.

ASCO strongly urges CMS to revisit and change the split/shared billing policy for 2024. The society will continue to work with the Administration and Congress to ensure that CMS’ split/shared billing policies will not have an adverse effect on cancer care delivery.

Read the position statement.

Bookmark ASCO in Action for updates as well as news, advocacy, and analysis on cancer policy.