Evaluation and Management FAQs

Split/Shared and Incident To Services

Please define the substantive portion of a split (or shared) visit in 2024?

Answer: The following factors apply in 2024 in determining the substantive portion of a split (or shared) visit:
- Total time spent by each contributing provider. The provider who spends and documents more than half of the total service time is considered the substantive provider
  Or
- The provider who performs and documents the substantive part of the medical decision making
Please provide a guideline for MDM documentation by the substantive provider.

Answer: The medical record must reasonably support the work relative to the MDM. This may include commentary on the findings documented by the other contributing provider or may include additional findings or details not previously noted by the other contributing provider, all of which played a part in establishing MDM and a plan of care. The substantive/billing provider must sign and date the medical record for the service.

In support of the physician’s role as the substantive provider, documentation of the physician’s findings and conclusions in developing the MDM are expected. The physician’s documentation must be robust enough to substantiate that greater than fifty percent of the medical decision making was performed by the physician.

Please define signature requirements for documenting a split/shared service.

Answer: The substantive (billing) provider is required to sign and date the medical record for the service. The medical record must also identify the other contributing provider and, when billing based on time, the amount of time spent by the other contributing provider. This is necessary to determine that the substantive provider spent more than half of the total time.
Please explain the differences between incident to and split/shared visits.

Incident to services are permissible only in the office environment and allow NPPs to bill for services under the supervising physician’s number, when specific supervisory and clinical requirements are met. Guidelines also permit clinical staff to perform services as part of a physician's or NPP's service, e.g., injection of a prescribed medication.

Split/shared services are permissible in the facility setting and allow physicians and NPPs to collaboratively perform inpatient and outpatient E/M services. The services may be billed based (as described above in FAQ number one) based on time or MDM.
Please explain how incident to rules apply in the office setting.

Answer: The concept of incident to billing in the office setting can apply in two ways:
- It may apply to office services performed by ancillary staff during a physician’s E/M encounter (e.g., antibiotic injection by an RN), which are integral to the physician’s service and included within the physician’s billing for the E/M service, or,
- It may apply to follow-up office E/M encounter for an established patient, performed by an NPP, subsequent to an initial E/M performed by a physician, and billed under the physician’s number. The original physician or a group member physician must be present and available in the office suite to provide oversight, and the record must reflect periodic oversight of the NPP’s plan of care. When the patient presents with a new problem(s), requiring changes to the plan of care, the visit again requires the physician’s direct participation.
  
  Please note that E/M services can only be billed on an incident to basis by practitioners whose scope of practice encompasses such services, e.g., NPs and PAs. While other employed individuals, e.g., nurses and registered dieticians, may participate in the physician’s encounter, only the physician or NPP may perform the E/M service.
Is it permissible for a clinical pharmacist working in a physician office to bill Medicare E/M services as ‘incident to’ the physician as long as incident to guidelines are met?

Answer: A clinical pharmacist working in physician billing may provide patient education, represented by CPT code 99211, incident to a physician when all requirements are met. Medicare rules do not permit clinical pharmacists to bill any other level of E/M services.

What are the guidelines for reporting 99211 in the case that an ancillary staff member performed the service (i.e., nurse visit).

Answer: In order to bill 99211 for a service performed by an office nurse, incident to requirements must be met and the billing provider must be present and available within the office suite.

When a patient is seen in a group practice by an NPP, can oversight in the office suite be provided by a group-member physician other than the patient’s usual physician?

Answer: In a group practice, it is acceptable to have an NPP perform an incident to service when another physician member of the group is in the suite and available for oversight as needed. Group members may provide cross coverage for each other and incident to guidelines can be met in this circumstance.

When providing oversight for incident to services, is it permissible for a physician to be present in the same building as the office site of service, but on another floor? In such circumstances, could a NPP bill under incident to guidelines?

Answer: The physician providing oversight for an NPP must be in the same office suite as the performing NPP in order to meet incident to rules. The physician’s presence outside of that office suite would preclude the NPP from billing the service as incident to, and this rule would apply to the physician’s presence elsewhere in the same building.

Can a clinical psychologist bill for an E/M service, either independently or under incident to or split/shared guidelines?

Answer: E/M services can only be performed and billed by physicians and NPPs for whom E/M is within the scope of practice. This excludes clinical psychologists and clinical social workers from performing E/M services, and also from billing for behavioral health codes that include medical evaluation and management, e.g., CPT codes 90805, 90807 and 90809. Please refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12 Section 190.5, where this rule is specified in a section pertaining to telehealth guidelines.

For a subsequent inpatient split shared visit, do the NPP and the physician have to do two separate notes or can they document their own face-to-face encounters on the same note?

Answer: Each provider should document his/her contribution to the service, with both notes indicating the service was “performed in conjunction with (NPP or MD).

Would you consider a shared/split service if the MD’s documentation was listed as an addendum on the NPP’s note?

Answer: Split/shared services in the hospital setting require performance of MDM or greater time spent by both contributing providers. The only way for a physician and NPP to describe their own personal contribution to the service is to document an individual note describing the portion of the service performed.

In order to bill the service as the “substantive” provider, the physician’s documentation would need to describe the physician’s work as exceeding the NPP’s work in formulating MDM or in spending more than half of the total visit time.

For time-based split/shared encounters, is there a requirement on how time is split between the physician and the NPP in seeing the patient?

Answer: There is no requirement regarding how much of the split/shared visit time should be spent by either provider. As always, time spent by each provider must be carefully documented, and the cumulative time for both is counted for the total visit time. When billing the services based on the cumulative time, the provider (either physician or NPP) who spent and documented the greater component of time is the provider who bills the service.

When a physician and NPP perform either a split/shared or incident to E/M service, do both providers have to be enrolled and credentialed in the Medicare Program?

Answer: Yes, both providers must be enrolled in Medicare in order for the service to be billed under the physician’s Medicare number.
Can a consultative service in the hospital setting be performed on a split/shared basis?

Answer: As of 1/1/2022, CMS has confirmed that consultative services may be performed on a split/shared basis.

Please explain how split/shared rules apply to prolonged services.

Answer: A prolonged service code may be added to a split/shared service that’s coded based on cumulative time, when all time requirements are met. Time spent by each contributing provider (MD and NPP) must be documented to support the base code and the addition of the prolonged service code(s).

Revised 10/10/2024