Evaluation and Management

Split/Shared and Incident To Services

  1. 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. 
    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 on either service components (history, exam, MDM) or cumulative time spent and documented. When billing based on cumulative time, the service is billed by the contributing provider (physician or NPP) who spent and documented the greater time component. 
  2. Please explain how incident to rules apply in the office 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), 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. 
  1. 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?

    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. 
  2. 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. 
  3. 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. 
  4. 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.
  5. 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. 
  6. 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). 
  7. 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 the medically necessary elements (history, exam, MDM) or cumulative time spent 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.
  8. 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. 
  9. 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. 
  10. Can a consultative service in the hospital setting be performed on a split/shared basis?

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

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

    Billing for a split/shared service is based on cumulative time, which supports addition of a prolonged service code(s), the split/shared rule also applies to the prolonged service(s). 

Reviewed 7/5/2022