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Nonphysician practitioner (NPP) billing for evaluation and management (E/M) and critical care services: A sea change now in effect!


In the 2022 Medicare Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) further refined E/M billing by addressing split/shared visits between nonphysician practitioners (such as nurse practitioners and physician assistants) (see, pp. 65150-9).

A split/shared visit is “an E/M visit in the facility setting that is performed in part by both a physician and an NPP who are in the same group, in accordance with applicable laws and regulations.” CMS recognized team-based care increased utilization of NPPs in the inpatient setting, typically under physician supervision rather than completely independent NPP practice. NPP-physician team-based care is widely prevalent on critical care, hospitalist, and specialty consultation services.

These new changes from CMS went into effect January 1, 2022. CMS now mandates the practitioner providing the “substantive portion” of the service must bill for the service. For the past 20 years, the substantive portion was largely defined by medical decision making (MDM): the physician often spent less face-to-face and/or non-face-to-face time than the NPP, but the physician could bill for the service based on MDM including a nuanced synthesis of data, and final approvals or revisions to decisions on additional evaluation and treatment. Beginning January 1, 2023, CMS will no longer define MDM as the substantive portion of the visit “because MDM is not necessarily quantifiable and can depend on patient characteristics (for example, risk).” Thus, CMS will define the “substantive portion” of the visit as the practitioner who spent >50% of the total of both face-to-face and non-face-to-face time, on the calendar day. 2022 is a transitional year allowing “the practitioner who spends more than half of the total time, or performs the history, exam, or MDM to be considered to have performed the substantive portion and can bill for the split (or shared) E/M visit.” During 2022, the visit level can be chosen based on MDM or time. In 2023, the visit level can still be chosen based upon MDM, but the billing provider is determined by who performed the “substantive portion” of the visit, which will be exclusively based upon which provider spent the most amount of time.

During 2022, when billing based on time, the practitioner spending the most time (the NPP or the physician) dictates who will be the billing provider. Alternatively, billing based on the substantive portion of the visit allows billing by the provider (NPP or physician) who completely performs the key component (history, physical examination, or medical decision making) that determines the level of the visit. With the new documentation guidelines, MDM is the only key component that can determine the visit level in the office setting. In 2023, only time-based billing will be in effect for choosing the billing provider in the inpatient hospital setting. Most importantly, time-based billing is already the only method for determining the billing provider for billing critical care services, based on the provider (NPP or physician) with the greater individual total of time.

This change represents a major shift in reimbursement for physician-NPP teams. Many physician compensation plans are based on a work relative value unit (wRVU) system. This time-based billing may shift attribution to the NPP and, thereby, disadvantage the physicians working with NPPs as they will no longer receive wRVU credit for team-based care delivery. This shift demands we all reexamine our compensation models, and how organizations attribute work value across their providers (both NPPs and physicians), with special consideration for how to credit physicians for their essential supervision of team-based care delivered and now billed by NPPs. Ideally, options for revising compensation models without changing the care delivery model would preserve the essential partnership between physicians and NPPs.

*The CHEST Health Policy and Advocacy Work Group includes Nikki Augustyn, Geoffrey D. Bass, MD, Jamie Cummings, Ian Nathanson, MD, FCCP, Emily Petraglia, Gulshan Sharma, MD, FCCP, Kelly Shriner, and John E. Studdard, MD, FCCP.

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