Introduction – Why Split/Shared Keeps Shifting Under Our Feet
Few Medicare topics generate more back-and-forth than split/shared evaluation-and-management (E/M) visits. The Physician Fee Schedule (PFS) Final Rule for 2024 rewrote the definition of “substantive portion,” kept the medical-decision-making (MDM) pathway alive for another year, and reaffirmed that every claim must carry HCPCS modifier FS—yet many hospitals still follow 2022 playbooks. Confusion leads directly to claim delays, take-backs, and audit risk. This article translates the current regulations into plain-English action items for revenue-cycle professionals, flags the most common pitfalls, and shows how to future-proof your workflows for the coming time-only environment.
1. Policy Pendulum: A Short History of a Long Debate
CMS first threatened to make “more than half of the total time” the sole determinant of the billing practitioner back in 2022. Industry groups warned that strict clock-watching would up-end team-based care and transfer revenue from physicians to non-physician practitioners (NPPs). CMS responded by delaying the mandate, first to 2023, then to 2024, and in the 2024 Final Rule it postponed once again—allowing either time or Medical Decision-Making to satisfy the substantive-portion test for the entire calendar year.
Crucially, the Final Rule also signaled that time will become the lone yardstick after this transitional period, though CMS stopped short of naming an irreversible date. That puts RCM leaders on notice: master today’s dual-path rules while quietly building the infrastructure for a time-only future.
2. Split/Shared—The Current Definition in Two Sentences
A split/shared visit is an E/M encounter in a facility setting—hospital inpatient, observation, outpatient department, emergency department, or skilled-nursing facility—performed on the same calendar day by a physician and an NPP from the same group. The service is billed under the NPI of whichever clinician performs the substantive portion, defined for now as either (1) more than half the combined time or (2) a substantive part of the MDM.
Note: Office visits, nursing-home visits billed under the consolidated care codes, and any service that by regulation must be performed by a physician are never eligible for split/shared billing.
3. Choosing—and Proving—the Substantive Portion
3.1 The Time Pathway
If you elect to bill on time, add every distinct minute each practitioner spends on qualifying activities: reviewing labs, performing the exam, counseling, documenting, coordinating care, or communicating with other professionals. Overlapping minutes count once. When one clinician logs > 50 percent of the total, that person is the billing provider. Keep a running log in the EHR; ISO-certified time stamps are ideal, but a clearly dated narrative entry also satisfies auditors.
3.2 The MDM Pathway
Under the MDM method, the billing practitioner must personally complete—and clearly document—the portion of decision-making that drives the visit level. CMS expects more than a cursory attestation. At a minimum, the note should:
- Identify the new or established problems evaluated.
- Detail the data reviewed or ordered.
- Spell out the risk-benefit analysis and the final management plan.
Because the billing practitioner’s work must be “substantive,” copying the NPP’s history or exam without fresh analysis will not pass muster.
3.3 Special Situations
- Critical Care: Because critical-care codes are based solely on time, > 50 percent of total time is the only way to establish the substantive portion.
- Prolonged Services: Once you add an appropriate prolonged-time add-on code, the > 50 percent rule continues to apply for the base and the add-on.
4. Modifier FS—Tiny Code, Giant Consequences
Every split/shared E/M claim must carry HCPCS modifier FS. Omitting it invites denials and, worse, overpayment findings on audit. EHRs should default the modifier onto any facility-based E/M code when two clinicians open the same encounter. Build a scrubber edit that stops claims missing FS before they hit the payer queue.
Signature rules: The billing practitioner must sign and date the note, and the record must clearly identify both individuals who provided care. Side-by-side or clearly labeled sections eliminate ambiguity.
5. Documentation Blueprint—Five Lines That Defend Every Audit
- Clinician IDs: “Seen by Jane Doe, MD, and Alex Smith, PA-C.”
- Setting and date: “Split/shared inpatient progress note, 14 Mar 2024, CPT 99233.”
- Distinct work: Separate paragraphs describing each practitioner’s contribution.
- Ownership statement: “MD performed decision-making driving today’s high-complexity MDM” or “MD: 18 min; PA: 12 min—MD logged > 50 percent total time.”
- Billing signature: Dr Doe’s electronic signature with timestamp.
Hospitals that roll these five items into a template see denial rates plummet and audit pass-rates soar.
6. High-Risk Scenarios—and How to Neutralise Them
- The Drive-By Attending: A physician scans the chart for two minutes, co-signs the PA’s note, and wants the service billed under the physician’s NPI. Without > 50 percent time or substantive MDM, the claim fails. Fix: hard-stop the note until qualifying documentation is entered.
- Duplicate Note Myth: Two separate notes do not guarantee compliance. Auditors ignore duplicate histories or exams; they look for unique, substantive work.
- ED Handoff: When an NPP starts in triage and a physician finishes in the bay, ensure overlapping minutes are not double-counted. Only one person can cross the 50-percent threshold.
- Post-Op Day 1: Surgeons often pop in for under three minutes. If that is all they document, the NPP must bill. Configure EHR alerts for low-minute physician entries.
- Critical-Care Tag-Team: Keep a bedside time log. Telephone and chart-review minutes count, but someone must clearly exceed half of the combined total.
7. Revenue-Cycle Impact—Turning Regulation into Reliable Cash
- Charge Capture: Embed an EHR flag that prompts coders to confirm FS and the chosen substantive-portion metric.
- Concurrent Audits: Review ten split/shared charts monthly; focus on time math and MDM attribution.
- Denial Management: Most MACs allow a reopened claim within a year if FS was forgotten. Build a rapid correction protocol.
- Provider Education: Badge-sized “cue cards” listing qualifying time activities and the five-line blueprint outperform hour-long webinars.
- Analytics: Track the percentage of split/shared volume billed under physician versus NPP NPIs. A sudden physician-heavy spike can signal documentation gaps.
8. Preparing for the Coming Time-Only Era
CMS has reiterated its intention to shift to a time-only definition once the current transition winds down. Whether that change drops next year or the year after, hospitals that start clock-ready workflows now will glide over the threshold instead of scrambling at the eleventh hour.
Action items:
- Map Current Workflows: Identify where time is lost or undocumented—handoffs, bedside teaching, phone updates.
- Install EHR Timers: Badge taps, quick-pick time buttons, or mobile apps cut estimation errors.
- Retrain Physicians: Many haven’t tracked minutes since residency. Offer quick refreshers plus live audit feedback.
- Model Compensation: If more visits end up under NPP rates, forecast the bottom-line impact and adjust RVU goals or bonus pools accordingly.
- Update Policies: Use neutral language—“When CMS transitions to a time-only requirement…”—so manuals stay current without annual rewrites.
9. Quick-Start Checklist for Compliance Leads
- Revise policy manuals to mirror the latest Final Rule language.
- Tweak EHR templates with FS defaults and time/MDM prompts.
- Launch a 30-minute refresher for all hospital-based physicians, NPs, and PAs.
- Audit 25 random charts; score against the five-line blueprint.
- Correct failures immediately, then re-audit monthly until pass-rates exceed 95 percent.
- Form a time-tracking task force to pilot technology and workflow solutions.
Conclusion – From Moving Target to Competitive Advantage
Split/shared rules no longer feel like the wild west—but they aren’t set in stone either. Right now, revenue-cycle teams must juggle dual metrics (time or MDM) while embedding modifier FS and rock-solid signatures into every facility E/M claim. Smart organisations treat today’s regulations as an opportunity: airtight documentation, proactive auditing, and early adoption of time-tracking tools lead to cleaner claims now and a painless transition when CMS finally locks in a time-only model. Master the blueprint above, and split/shared visits will shift from compliance headache to dependable revenue stream.
