CMS E&M Changes: Some MACs are Getting it Wrong

As the MACs have started publishing their 2022 guideline instructions and interpretations, some of the information is confusing – or just plain wrong.

EDITOR’S NOTE: RACmonitor launches an occasional series, “RAC Rants,” with this first post by past president of the Healthcare Business and Management Association (HBMA) Holly Louie. Entries are welcome at

The 2022 Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Final Rule made significant changes to split/shared visit policies. Some of the changes are certainly welcome and long overdue. The changes require careful review of efficient workflow, medical records, documentation policies, electronic health record (EHR) templates, coding updates, and more. These changes were effective Jan. 1, 2022, along with numerous other changes requiring similar or even more extensive documentation, coding education, and compliance updates. The fact that 2022 is a transition year to allow split/shared visits to be billed under two methodologies, time or key components, adds even more challenges and confusion. It’s a massive undertaking, and our physicians and practitioners need to be confident that what they are told by the CMS Medicare Administrative Contractors (MACs) is current and accurate.

Unfortunately, as the MACs have started publishing their 2022 guideline instructions and interpretations, some of the information is confusing – or just plain wrong! 

In the Final Rule, CMS stated that they finalized a policy that any individual who is authorized under Medicare law to furnish and bill for their professional services may review and verify the medical record for the services they bill, rather than re-document notes made by others for the services the reporting clinician furnishes and bills. CMS also stated that the record should identify the two practitioners who shared the visit, and that it would be “helpful” if each documented their time/work. But identification is not the same as fully documenting individual detailed service notes. “Helpful” is not the same as “mandatory.” The Final Rule leaves much of the methodology of documentation to individual groups.

Perhaps most importantly, CMS also discussed why they were not leaving interpretation open to the MACs, due to concern of inconsistency in rule application. It appears that the MACs did not get the message, or CMS is unaware of what they are publishing for their jurisdictions. Two erroneous statements are detailed below.

On Jan. 3, National Government Services (NGS) provided two questions and answers specific to documenting split/shared services. When asked if the physician and non-physician practitioner (NPP) have to create two separate notes, or whether they can combine their notes into one, NGS responded that each should document his or her own note, indicating that the service(s) were “performed in conjunction with (NPP or MD (doctor of medicine)).”

A second question asked if the physician’s documentation could be an addendum to the NPP’s note. NGS responded, “split/shared services in the hospital setting require performance of the medically necessary elements (history, exam, MDM) or cumulative time spent by both the billing physician and NPP. The only way for a physician and NPP to describe his/her own personal contribution to the service is to document an individual note describing the portion of the service performed.”

Far more concerning are the completely erroneous instructions from Palmetto GBA regarding split/shared critical care services and nursing services. In information last updated Jan. 22, a question of whether critical care could be a split/shared service was published. Palmetto’s reply, in direct contraction to the Final Rule, states “No. Split/shared services cannot be performed for nursing facility services, critical care or procedures.” Although there are some nursing home visits that cannot be split/shared, it is not all of them. Critical care can be split/shared. At least they got the procedure portion correct. If this note is a carry forward from previous years, due care in reviewing what was included was clearly lacking. For those who don’t live in the Federal Register and CMS publications, they won’t know it’s completely wrong.

Our physicians and their agents must be extremely diligent about monitoring MAC updates and education for accuracy. They also need to know that what they read may not be correct information. While we can certainly notify the MACs, I strongly recommend also notifying CMS of the errors.

It’s an unfortunate situation when physicians are held accountable for knowing and complying with the rules, but the MACs don’t seem to be held to the same accuracy standards.

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