Last Modified: 9/16/2016 Location: FL, PR, USVI Business: Part B
Split and shared visits FAQ
A: A split/shared evaluation and management (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 non-physician practitioner (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 NPP both must be in the same group practice or employed by the same employer.
The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and non-facility clinic visits, and prolonged visits associated with these E/M visit codes). The split/shared E/M policy does not apply to critical care services or procedures.
Common split/shared visit scenarios
• Hospital inpatient/outpatient/emergency room setting:
• When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's National Provider Identifier(NPI).
• If there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPP's NPI.
• Payment will be made at the appropriate physician fee schedule rate based on the Provider Transaction Access Number (PTAN) entered on the claim.
EXAMPLE: If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service.
• Office/Clinic setting:
• In the office/clinic setting when the physician performs the E/M service the service must be reported using the physician’s NPI.
• When an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed “incident to” if the requirements for “incident to” are met and the patient is an established patient.
• If “incident to” requirements are not met for the shared/split E/M service, the service must be billed under the NPP’s NPI, and payment will be made at the appropriate physician fee schedule payment amount.
EXAMPLE: In an office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the "incident to" requirements are met, the physician reports the service. If the “incident to” requirements are not met, the service must be reported using the NPP’s NPI.
Documentation for split/shared visits should follow the documentation guidelines for any E/M service: each physician/NPP should personally document in the medical record his/her portion of the E/M split/shared visit and legibly sign and date the record. The documentation must support the combined service level reported on the claim.
Source: CMS internet-only manual (IOM) Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, Section 30.6.1
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