Shared or split visits are one of the important services that medical billing and coding companies help healthcare providers report. In 2002, the Centers for Medicare & Medicaid Services (CMS) issued instructions giving non-physician practitioners (NPPs) and their supervising physicians increased flexibility for hospital and office billing of evaluation and management (E/M) services. These rules allow NPPs and physicians who work for the same entity to share Medicare patient visits on the same day and bill the combined work under the physician’s provider number. The work of the physician and the NPP are “combined” into a single E/M service.
According to the Medicare’s Part B payment policy, a split/shared E/M visit is “a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service.” The policy specifically indicates that “a substantive portion of an E/M visit” means “all or some portion of the history, exam or medical decision making key components of an E/M service.”
Advantages of NPP Services
According to 2018 MGMA DataDive Cost and Revenue data, using more non-physician providers boosts revenue and productivity (www.healthleadersmedia.com). The report found that by using NPP services, hospital-owned primary care practices can earn up to $131,770 more in revenue after operating costs per physician. This applied for all specialties. The benefits of using NPP services are:
- Invaluable patient education support
- High quality care with comparable patient outcomes
- Wide range of patient care services provided in the office setting allow physicians to see a consistent volume of patients
- Help offset physician shortages and increase access to care
- Optimize the healthcare team by assuming responsibility for less-complex patients
- Help minimize length of stay and ensure focus on evidence-based care
- Assist in the development of facility quality controls
The success of the team depends on proper and full alignment of all components.
In a split or shared visit, a qualified NPP works either in collaboration with or under the supervision of a physician to provide incident-to or shared services, or provide support the physician in providing the following services: physical exams; diagnosing and treating illnesses; ordering and interpreting tests; counseling on preventive health care; assisting in surgery, and prescribing medications.
E/M services that can be reported as shared/split visits include:
- Hospital inpatient services
- Hospital outpatient services
- Hospital observation services
- Emergency department services
- Hospital discharge services
- Office and non-facility clinic visits
- Prolonged visits associated with any of the above E/M services
Here is an example of a split/shared visit in a hospital where two providers from the same group provide a service for a patient on the same day: A 65-year-old patient is admitted for chronic obstructive bronchitis and breathing difficulty. A nurse practitioner evaluates the patient, documents the service, and informs the attending physician about the patient’s condition. The physician later sees the patient and agrees with the patient’s current treatment plan. In this scenario, one provider can bill for the shared/split service if the services are appropriately documented and Medicare billing criteria are met.
Billing for Shared/Split Services
Organizations employing NPPs should be knowledgeable about state and federal regulations, as well as billing and documentation standards related to NPP services. The shared/split billing policy only applies to Medicare beneficiaries. Key rules for shared visit documentation and reporting are as follows:
- Shared/split billing regulations recognize only E/M services provided in specific facility-based settings: EDs, outpatient hospital clinics, or inpatient hospitals. Critical-care services and procedures are not included.
- Incident-to billing is applicable for services that an NPP provides, which are incidental but integral to the patient’s care. These services should meet specific Medicare reimbursement guidelines.
- For incident-to payment, the service must be provided in a “noninstitutional setting,” which CMS defines as “all settings other than a hospital or skilled nursing facility.”
- In an office/clinic, shared/split visits must meet all incident-to requirements.
- Split/shared services should be billed when both the NPP and the physician provided services at the visit.
- To meetincident-to requirements, the NPP can see only existing patients with an established plan of care by a credentialed physician.
- The incident-to service must be the type of service usually performed in the office setting, and be part of the normal course of treatment of a diagnosis or illness.
- Both the credentialed physician and the qualified NPP providing the incident-to service must be employed by the group entity billing for the service.
- Documentation by the attending physician should demonstrate their personal or face-to-face encounter with the patient.
- The documentation should clearly state the services that the NPP performed and which the physician performed. Both provider should date and legibly sign their corresponding note, and identify the visit level supported by the cumulative encounter.
- Only one claim can be submitted for a shared/split service. The services can be reported with either the physician’s NPI or the NPP’s NPI.
- In the Hospital Inpatient/Outpatient and Emergency Department Setting: if the physician simply reviews the patient’s medical record and discusses the case with the NPP, the service must be reported under the MLP’s provider number.
When documenting a shared/split visit, the physician’s notes should be linked to the NPP’s notes and it should be confirmed that the physician provided at least one E/M element. With proper documentation, medical billing companies can help providers ensure accurate reporting of shared/split services for maximum reimbursement.