Thursday, August 20, 2015

What is the difference between “incident to” and split-shared billing as it applies to our mid-level providers?



This is a common question and also a major area of auditing concern, since this is closely investigated by the Office of Inspector General, RACs (recovery audit contractors) and individual payors. Make sure that all providers and billing staff are aware of the differences, which are listed below:

Incident to Services
To qualify as “incident to,” services must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. The physician does not have to be physically present in the patient’s treatment room while these services are provided, but the physician must provide direct supervision. That is, the physician must be present in the office suite to render assistance, if necessary. The patient record should document the essential requirements for incident to service. If the physician is in the ambulatory surgery center, even if it is adjacent to the office, that does not count as direct supervision

CMS MLN Matters SE0441 for “Incident to” Services

  • “Incident to” services must be part of the patient’s normal course of treatment.
  • Once treatment has been adjusted by the nurse practitioner (NPP), or if a new problem is addressed during a follow-up encounter, “incident to” services are no longer met, and the service must be billed under the NPP who performed the service.
  • “Incident to” services are not allowed in inpatient or nursing facility settings.
  • Physician must be in the office suite and review the record to qualify for billing “incident to” — does not have to be the physician who initiated the patient’s treatment. 

Example: 33-year-old female presents new to the GI practice for evaluation of atypical GERD symptoms. Dr. Brown completes a full history and physical, and then decides to prescribe a new regimen. He instructs the patient to return to clinic in one month.
• This is a billable new clinic visit under Dr. Brown.

Example: 33-year-old female with problems noted above returns to see the NPP for follow up. Patient reports that she feels better. NPP instructs the patient to continue with the same medication and return in three months for re-evaluation or sooner, if symptoms worsen. Physician in clinic reviews the NPP’s documentation and agrees with treatment plan.
• Billable follow-up clinic visit under physician — “incident to” services met.
Example: 33-year-old female with problems noted above returns to see the NPP for follow up and symptoms have recurred, along with dysphagia. After the NPP examines the patient, the patient is scheduled for an EGD. Physician did not see the patient that day.
• Billable visit under the NPP — “incident to” services not met; NPP changed course of treatment.

Split/shared Services
“A split/shared E/M visit is defined by Medicare Part B payment policy as 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. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer.”

Medicare Claims Processing Manual, Physicians/Nonphysician Practitioners

  • Both the physician and the NPP must each personally perform part of the visit, and both the physician and the NPP must document the part(s) that he or she personally performed.
  • Split/shared services are not billable in the skilled nursing facility/non-facility (SNF/NF) setting.
  • Split/shared policy does not apply to critical care and procedures.


The following examples are unacceptable addendums by the physician:

  • “I have personally seen and examined the patient independently, reviewed the PA’s Hx, exam and MDM, and agree with the assessment and plan as written,” signed by the physician. 
  • “Patient seen,” signed by the physician. 
  • “Seen and examined,” signed by the physician. 
  • “Seen and examined and agree with above (or agree with plan),” signed by the physician. 
  • “As above,” signed by the physician. 
  • Documentation by the NPP stating, “The patient was seen and examined by myself and Dr. X., who agrees with the plan,” with a co-sign of the note by Dr. X. 
  • No comment at all by the physician, or only a physician signature at the end of the note.


WPS Medicare, Part B, Inpatient Split/Shared Evaluation and Management (E/M) Services
Example: 55-year-old male seen as a follow up in the hospital for acute blood loss anemia and possible gastric ulcer. PA performs an interval history, detailed exam and moderate decision making.

Supervising physician’s addendum:
“I personally examined the patient and agree with the assessment and plan noted above. Patient notes tenderness in the LUQ and positive bowel sounds. His hemoglobin is still low following two units of blood. I’m concerned about ongoing blood loss and abdominal tenderness. I would like to get the first available EGD to look for source of bleeding and pain.”

  • Billable visit under the supervising physician — split/shared criteria met.


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