Medicare’s Split/Shared Visit Policy

Rules for Medicare’s split/shared visit policy can be a lot to choke down. Here’s our simplified interpretation to make it easier to digest.

By Elin Baklid-Kunz, MBA, CPC, CCS

Medicare defines NPPs as physician assistants (PAs), nurse practitioners (NPs), and clinical nurse specialists (CNSs).
These instructions are referred to as Medicare’s Split/Shared Visit Policy. The policy is one of three billing options for NPPs:

1. NPPs own provider number receiving 85 percent of the MPFS amount
2. Incident-to the physician receiving 100 percent of the MPFS
3. Split/shared service receiving 100 percent of MPFS

Billing using the NPP’s provider number is easy but can cause confusion about Medicare’s Split/Shared Visit Policy when it relates to new patient office or other outpatient visits (CPT^® 99201–99205).

Medicare’s Split/Shared Visit Policy

The definition of split/shared visits can be found in the CMS Internet Only Manual (IOM): Medicare Claims Processing Manual Publication 100-04, chapter 12, section 30.6.1.H Split/Shared E/M Visit:
“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.”

Different Rules for Different Settings

The split/shared E/M visit policy applies only to selected settings: hospital inpatient, hospital outpatient, hospital observation, emergency department, and office and non-facility clinics. A split/shared E/M visit cannot be reported in the skilled nursing facility (SNF) or nursing facility (NF) setting.
When a non-hospital outpatient clinic or physician office E/M visit is split or shared between a physician and a NNP, the E/M encounter may be billed under the physician’s name and provider number if the patient is an established patient and the incident-to rules are met. (Note: Medicare clarifies that incident-to billing is not allowed for new patient visits).
Let’s look at an example. An established patient visits. The NPP performs the history and physical exam and the physician performs the medical decision-making. The “incident-to” requirements are met. In this same example, if the physician and the NPP shared the visit and it does not meet incident-to rules, the entire visit is billed under the NPP’s provider number.
When a hospital inpatient, hospital outpatient, or emergency department E/M visit is split or shared between a physician and a NPP from the same group practice, the E/M visit may be billed under the physician’s name and provider number if the physician provides any face-to-face portion of the E/M encounter (also applies to same day as the NPP’s portion) and the physician personally documents in the patient’s record the physician’s face-to-face portion of the E/M encounter with the patient. (Co-signatures are NOT sufficient).
An example of an E/M visit that may be billed under the physician’s name and provider number is hospital rounds at different times of the day on the same date of service. In a provider-based physician office (i.e., hospital outpatient department) or the emergency room, an example is a new or established patient visit where the NPP performs the history and physical exam, and the physician is the medical decision-maker.

Rule Applies ONLY to Selected E/M Visits

The split/shared E/M visit rule applies only to selected E/M visits such as these in the hospital settings:

• hospital admissions (99221-99223)
• follow-up visits (99231-99233)
• discharge management (99238-99239)
• observation care (99217-99220, 99234-99236)
• emergency department visits (99281-99285)
• prolonged care (99354-99357)
• hospital outpatient departments (provider-based visits) (99201-99215)

In a physician office setting, use codes 99211-99215 for an established patient with an established plan of treatment. Incident-to requirements must be met.
Remember: Split/shared visits do not apply to consultations (99241-99255), critical care services (99291-99292) or procedures.

Relationship to Incident-to

To bill a split/shared visit in the physician office setting, the visit must meet incident-to rules. For the services of a NPP to be covered as incident-to the services of a physician, the services must meet all the requirements for coverage specified in the CMS IOM: Medicare Benefit Policy Manual Publication 100-02, chapter 15 §60-61:

• The service or supplies are an integral, although incidental, part of the physician’s or practitioner’s professional services
• The services or supplies are of a type that are commonly furnished in a physician’s office or clinic
• The services or supplies are furnished under the physician’s/practitioner’s direct supervision
• The services or supplies are furnished by an individual who qualifies as an employee of the physician, NPP or professional association or group that furnishes the services or supplies
• The service is part of the patient’s normal course of treatment, during which a physician personally performs an initial service and remains actively involved in the course of treatment

According to the Medicare Benefit Policy Manual, incident-to apply only to non-institutionalized settings (i.e., not hospital or SNF settings); section 60.1B of the Medicare Claims Processing Manual states:
“For hospital patients and for SNF patients who are in a Medicare covered stay, there is no Medicare Part B coverage of the services of physician-employed auxiliary personnel as services incident to physicians’ services under 279H§1861(s)(2)(A) of the Act. Such services can be covered only under the hospital or SNF benefit and payment for such services can be made to only the hospital or SNF by a Medicare intermediary.”

Can New Patients Office or Other Outpatient Visits (99201–99205) be Split/Shared?

Because incident-to criteria can be applied only in the office and non-facility clinic, the patient must be established. A hospital outpatient clinic/office is considered a hospital or facility setting, and not a non-institutional setting. Incident-to regulations do not apply and New Patient Office or Other Outpatient Visits (99201–99205) can be reported as a split/shared visit in the hospital outpatient clinic/office (POS 22). The physician must perform some aspect of the E/M service with the patient face-to-face and both the NPP and the physician must personally document what he/she performed.
Remember: Exclude the NPP’s salary and benefits from the hospital’s cost report when the NPP performs professional services. If the NPP does both facility and professional services, keep time sheets so the expense for professional services can be excluded from the facility’s cost report.
In a provider-based clinic/office, the cost for the hospital staff is reported in the facility’s cost report and reimbursement for the service is received through the facility payment. If the NPP performs professional services, remember to exclude the NPP’s salary and benefits from the cost report. If the NPPs perform both hospital and professional services, keep track of the time spent on professional services so this component can be excluded from the cost report.
The cost report manuals are paper based manuals found at:
www.cms.hhs.gov/Manuals/PBM/list.asp
(publication 15: Provider Reimbursement, Provider Reimbursement Manual Part 1
chapter 21: Cost Related to Patient Care, section 2108: Reimbursement For Services by Provider-Based Physicians)
Provider-based regulations can be found in Transmittal A03-030, CR 2411, April 18, 2003: www.cms.hhs.gov/transmittals/downloads/A03030.PDF

Documentation of Split/Shared Visits

Documentation for split/shared visits should follow the documentation guidelines for any E/M Service, and you must follow these documentation requirements:

• Each physician/NPP should personally document in the medical record his/her portion of the E/M split/shared visit.
• The physician’s documentation must clearly indicate that a face-to-face visit took place. (i.e, documenting an exam component to substantiate the physician had a face-to-face visit with the patient, is recommended.)
• Documentation must support the combined service level reported on the claim.
• Auxiliary staff may document the review of systems, past family history, and social history. The physician and NPP must personally review this documentation and confirm and/or supplement it in the medical record.
• If the physician does not personally perform and document a face-to-face portion of the E/M encounter with the patient, then the E/M encounter is not billed under the physician’s name and provider number and is billed only under the NPP’s name and provider number.
• If the physician’s participation is only reviewing the patient’s medical record, the service is billed under the NPPs name and provider number. Payment will be made at the appropriate physician fee schedule based on the provider number entered on the claim.

Acceptable Physician Documentation

Because teaching physician services involving residents is somewhat analogous to split/shared visits, these examples from the CMS material on teaching physician services (CMS Pub.100-4, Chapter 12, Section 100.1.1.A General Documentation Instruction and Common Scenarios), help establish acceptable documentation for split/shared visits:

• “I performed a history and physical examination of the patient and discussed his management with the NPP. I reviewed the NPP note and agree with the documented findings and plan of care.”
• “I saw and evaluated the patient. I reviewed the NPP’s note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”
• “I saw and evaluated the patient. Agree with NPP’s note but lower extremities are weaker, now 3/5; MRI of L/S Spine today.”
• Examples of unacceptable documentation by a physician:
• “Agree with above,” followed by legible countersignature or identity.
• “Rounded, Reviewed, Agree,” followed by legible countersignature or identity.
• “Discussed with NPP. Agree,” followed by legible countersignature or identity.
• “Seen and agree,” followed by legible countersignature or identity.
• “Patient seen and evaluated,” followed by legible countersignature or identity.
• A legible countersignature or identity alone.

Such documentation is not acceptable as it is not possible to determine whether the physician was present, evaluated the patient, and/or had any involvement with the plan of care.

Scribing is Not a Billable Service

A scribe’s role is to document in the medical record  a physician’s visit with the patient. In a hospital setting, a scribe makes rounds with the physician and documents the visit. Scribing is not a billable service and is not always straightforward. For example, it is no longer considered scribing if the NPP adds an opinion to the progress note.
If your hospital or office uses scribes, establish a protocol that clearly outlines scribes to not render any opinions and to provide an accurate transcription of  physicians’ comments. Watch out for scribes who improve documentation to facilitate optimization of the claim to maximize revenue.
Guidelines for scribes published by First Coast Service Option, the Part B carrier for Florida and Connecticut in the third quarter 2006 Part B update (www.floridamedicare.com/Part_B/Medicare_B_Update/Archive/106399.pdf) are:
If a nurse or NPP acts as a scribe for the physician, the individual writing the note, history, discharge summary, or any entry in the record; should note “written by X, acting as scribe for Dr. Y.” Dr. Y should co-sign, indicating the note accurately reflects work and decisions made.
It is inappropriate for an employee of the physician to make rounds and write entries in the record, and then for the physician to make rounds several hours later and note “agree with above,” unless the employee is a licensed, certified provider (PA, NP) billing Medicare for services under his/her own name and number.
Scribes should record entries upon dictation by the physician, and should clearly document the level of service provided at that encounter. This requirement is no different from other encounter documentation requirements.
Medicare pays for medically necessary and reasonable services, and expects the person receiving payment to deliver services and create the record. There is no carrier Part B incident-to billing in the hospital setting (inpatient or outpatient). The scribe should only write what the physician dictates and does, acting independently there is no payment for this activity.

Understand Private Payer Differences

There is a distinction between Medicare regulations and private payers’ policies. Medicare rules do not necessarily impact private payers. Some payers may defer to state law, so understand your state’s scope of practice. Follow the requirements set out by private payers. Some hospitals query private payers to see what their rules are. An alternative to querying the private payers is to send the private plans a certified letter advising the hospital’s procedures plan for billing NPP service, unless the plan advises the hospital otherwise, in writing. When querying payers about policies, ask how to report services such as critical care and consultations.
Most private payers do not issue numbers to NPPs and request that billing occur under a supervising physician. Some payers may only ask to follow state law when NPPs deliver care. For such cases, it might be appropriate for the NPP to provide care without a physician face-to-face encounter in the emergency room and bill the private payer under the physician’s number.

Follow Medicaid’s State Rules

Medicaid also has different rules from Medicare when it comes to NPPs. Check your local state Medicaid Web site for your state’s rules. Medicaid pays NPPs on a separate fee schedule and has a separate limitation and coverage book for NPPs.
In Florida, NPP services under the direct supervision of a physician may be billed using the physician’s provider number instead of the NPPs provider number with some exceptions. Florida Medicaid direct supervision means the physician is on the premises when the services are rendered and he/she reviews, signs, and dates the medical record.
 

Get on Target with Split/Share Visits Compliance

In January’s incident-to article, Robert Pelaia Esq., CPC identified incident-to billing as completely transparent to the payer. This transparency exists for split/shared visit billing as well. When a claim for a split/shared visit is received for reimbursement, it looks just like a claim for a physician service and the provider usually gets paid for the claim even if it did not comply with the split/shared visit policy. Although transparent to the payer, non-compliance with the split/shared visit policy could be an easy target for Recovery Audit Contractors (RACs) when the permanent RAC program starts. In the revised scope of work released on Nov. 7, 2007, E/M codes were added to the services list that RAC can review. The RAC will also have hospital and provider specific medical record request limits and they may only send the provider one review result per claim. This may lead to auditors checking for multiple issues before sending denial letters. Because the RACs have the complete medical record and the claims submitted, it will be very easy to identify a progress note documented by the NPP and merely signed by the physician.

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