Reviewing Recent Updates to Coding Split or Shared Visits

Split or shared visit coding has seen multiple updates over the last year, including new CPT codes, deletions, and revisions for 2025. For healthcare providers, medical coding services, and medical coding companies in USA regions, understanding these changes is essential to proper billing, a healthy revenue cycle, and lower denial rates.

This blog will walk you through some of the nuances of split or shared visits and what you should do to support your revenue cycle strategy.

Split or shared visits occur when a physician and a non-physician practitioner (NPP) from the same group work together to provide evaluation and management (E/M) services to a patient in a facility. When these visits are coded properly, it is more likely that the correct practitioner will be reimbursed for their work, based on who performed the "substantive portion" of the visit [1]. 

Since team-based care is becoming increasingly common, split or shared visits have become a problem for many billing departments. Coding these visits accurately can be challenging, especially as guidelines continue to evolve.

The practitioner who performs the substantive portion of an E/M visit is who the bill is attributed to. This concept is defined as more than half of the total time spent or a significant part of the medical decision-making (MDM). As an example, in critical care visits, it is determined solely by time, while other E/M visits may use either time or MDM as the basis for billing. But CMS and CPT guidelines differ in how they handle split/shared visits. 

CMS

CMS defines split/shared visits as E/M services that are provided in a facility setting by both a physician and an NPP within the same group. For Medicare, the service is billed under the provider who performs the substantive portion of the visit. This standard applies only to institutional settings like hospitals and skilled nursing facilities (SNFs). Medicare requires clear documentation of the roles of both providers and the time spent.

CPT 

CPT guidelines do not explicitly define split/shared visits. Instead, they emphasize that E/M services should reflect the work of the provider who performs the face-to-face encounter and makes the management decisions. CPT guidelines are generally more flexible and do not restrict split/shared visits to specific settings.

Addressing Ambiguities

Differences between CPT and CMS guidelines can create complexity when billing non-Medicare carriers [2]. Billers working Medicare claims should prioritize Medicare regulations over CPT guidelines, making sure that the substantive portion is documented and billed correctly per CMS requirements. For other carriers, coders should follow CPT rules along with the individual payer contract specifications. 

This difference puts more burden on coders to check contracts and follow payer-specific rules to avoid claim denials or audits. Revenue cycle leaders have the burden of ensuring that billing staff are trained to navigate these complexities and apply the correct guidelines based on the payer.

The updated guidelines regarding split/shared visits impact medical coding and billing services in the USA for Medicare patients [3]. Proper compliance requires coding and billing staff that have a deep understanding of the definition of a split/shared visit and the substantive portion, as well as proper billing practices for split/shared E/M visits. For reasons such as this, many providers have decided to outsource their medical billing and coding. 

The Centers for Medicare & Medicaid Services (CMS) updated its policies in the CY 2024 Physician Fee Schedule final rule, which is reflected in CR 13592. This update revised Section 30.6.18 of the Medicare Claims Processing Manual, Chapter 12, to align with the new guidelines. According to CMS, the practitioner who performs the substantive portion of the visit – either by spending more than half of the total time or by completing the primary part of the medical decision-making (MDM) – is who the bill should fall under. 

The CPT update introduces significant changes to split and shared visit coding, including 270 new codes, 112 deleted codes, and 38 revised codes. Among these updates, the E/M guidelines for split/shared visits have better clarification. The 2025 update provides additional clarity on the determination of what constitutes a substantive portion. For time-based criteria, the practitioner who spends the majority of the total time on the date of the encounter can bill for the service. For MDM-based criteria, the practitioner who approves the care plan and takes responsibility for managing the patient’s problems and associated risks is considered to have performed the substantive portion. These updates aim to streamline the coding and billing process and reduce ambiguities, ensuring that providers and medical coding services can accurately assign codes based on the updated guidelines.

Improving Your Split and Shared Visit Coding Results with 3Gen Consulting

CMS and CPT guidelines have provided additional clarity, but ambiguities remain, particularly in reconciling Medicare regulations with CPT guidelines. For healthcare providers and revenue cycle leaders, there is increased pressure to maintain high levels of training and competence in their teams. 

As the healthcare landscape continues to evolve, outsourcing medical billing and coding can help revenue cycle leaders stay ahead of regulatory changes and improve revenue cycle results. To learn more about how we can support you in these goals and continue your search for medical coding companies in USA, contact us today.