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Split/Shared and Incident To Services

  1. Can an initial office visit be performed jointly by a physician and NPP and billed by the physician as a split/shared service?

    Answer:
    An initial office visit requires three out of three components and all three components must be performed and documented by the billing provider. The billing provider may be either a physician or a NPP, but the concept of split/sharing an initial visit is not applicable. Split/shared visits in the office setting must be in compliance with incident to rules, so first visits are excluded. Subsequent office visits may be split/shared when both a physician and NPP participate actively in the visit and incident to guidelines are met. Subsequent visits may also be billed incident to when performed solely by an NPP and incident to guidelines are met. Added 4/17/2018
     
  2. Please clarify billing for procedures performed by NPPs in the hospital setting, when an attending physician is present and/or available to the NPP for supervision.

    Answer:
    The concept of supervision by a physician does not apply to services performed by NPPs in the hospital setting; this is reserved for services performed by residents in GME programs, whose hospital services may be billable when supervised by an authorized teaching physician.

    In the hospital setting, NPPs are usually group practice members and may perform procedures for which they are qualified by their training, certification, hospital by-laws and state scope of practice. Examples of these procedures include, but are not limited to, endotracheal intubation, central venous line placement and insertion of surgical drains. Such procedures generally do not require participation by multiple providers; they are billable only by the provider who actually performs the service.

    When a procedure such as those described above is performed in the hospital setting by an NPP, the service is to be billed using the NPP’s NPI. It is not permissible to bill the service under a physician’s NPI unless the physician actually performed the service. The physician’s availability to the NPP does not make the service billable on an incident to basis, since the incident to concept is only applicable in the office setting and does not apply to hospital services, whether of an inpatient or outpatient nature. The service is also not billable as a split/shared service, since there was no actual physician participation in the key element(s) of the service. Added 1/4/2018
     
  3. Please explain the differences between incident to and split/shared visits.

    Answer:

    • Incident to visits 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.
    • Split/shared visits entail direct performance and participation by the physician under whose number the service will be billed. Split/shared visits may occur in either the office or hospital environment, although the concept generally applies more often in the hospital setting.

      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) 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 a 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.  

      For incident-to visits, time for the base visit is counted as spent by the rendering provider. 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, they cannot perform an E/M service without direct physician participation.

      Split/shared services  are those in which both a physician and NPP actively participate, each fulfilling and documenting at least one required element of the E/M service. Split/shared services can be performed in either the office or hospital setting; the split/shared requirements apply to all services jointly performed by physicians and NPPs. A service performed in the hospital by an NPP alone must be billed under the NPP’s billing number. The concept of physician supervision without direct performance/participation does not apply to hospital services. Updated 10/17/2017

  4. 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:
    Clinical pharmacists are not Medicare-enrolled providers and cannot bill services to Medicare. CPT code 99211 may be used to represent a clinical pharmacist’s service, but only in the context of incident to guidelines. This means that the CPT code 99211 service in which the clinical pharmacist participated is billed by the supervising physician, who remains available throughout the service for supervision. Updated 8/29/2017
     
  5. Please define the appropriate level of coding for education relative to chemotherapy.

    Answer:
    There are no pre-set E/M levels for any service. If the education on chemotherapy is performed by clinical staff, it may qualify for billing as CPT code 99211, but only when all incident to requirements are fully met and documented. If education/counseling on chemotherapy issues is provided by a physician or NPP during the course of an office visit, and represents more than 50% of the time spent in the visit, the visit may be coded based on the total time spent. Updated 8/29/2017
     
  6. Can a clinical pharmacist bill 99211 incident to a physician, if the incident to guidelines are met?

    Answer:
    The pharmacist can provide services within his or her scope that are “incident to” a physician and the physician may bill for them as long as they are medically necessary. Only a 99211 may be billed and not a higher level for these services. All of the “incident to” rules would need to be met. Updated 6/9/2017
     
  7. 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. Updated 6/9/2017
     
  8. When a patient is seen in a group practice by a 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. Updated 6/9/2017
     
  9. 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. Updated 6/9/2017
     
  10. Is it permissible under Medicare for a clinical pharmacist working in a physician office to bill evaluation and management services as “incident to “ the physician as long as incident to guidelines are met?

    Answer:
    E/M services may only be billed on an incident to basis by NPP (NPs and PAs) who are Medicare-enrolled and permitted to bill such services independent of a physician in other circumstances. E/M services are not within the scope of practice for clinical pharmacists and, as such, may not be performed independently by these individuals as incident to a physician’s services.  

    A physician or NPP (NP or PA) may bill for an E/M service in which one or more elements have been enhanced by the work of other licensed practice employees, such as licensed nurses, physical therapists or clinical pharmacists, but the services of these employees are considered part of the physician’s or NPP’s service, and the billing provider is responsible for insuring that all incident to requirements are met. Updated 6/9/2017
     
  11. 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, (1 MB) where this rule is specified in a section pertaining to telehealth guidelines. Updated 6/9/2017

  12. 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). Updated 8/29/2017
     
  13. 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 by of at least one required element 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.

    Example: “I have seen and examined the pt. with the PA and agreed with A/P and physical exam findings (and then a summary of items/data already listed by the PA,” the physician is indicating his/her participation in the physical examination and review of the medical decision making; this would be adequate to support the physician’s participation. Updated 6/9/2017
     
  14. 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. Updated 6/9/2017
     
  15. 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. Updated 6/9/2017
     
  16. Can a consultative service in the hospital setting be performed on a split/shared basis?

    Answer:
    CMS rules on consultative services have not changed, despite the use of standard E/M coding for inpatient and outpatient consultative services since 2010.

    When a provider requests the consultative opinion of another provider, the consulting provider must perform the service independently, and cannot split/share the required elements of the consultative E/M service. Updated 6/9/2017

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Split/Shared and Incident To Services
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