Split/Shared E/M Encounters
By Jean Acevedo, LHRM, CPC, CHC, CENTC
One trend that is inarguably growing is the use of Nonphysician Practitioners (Nurse Practitioners, Physician Assistants) in physician practices. In the inpatient setting, physicians often are billing the services of these practitioners as split/shared visits. What I have been surprised to find is such a broad lack of understanding of the requirements for billing under CMS’s policies (see Chapter 12 of the CMS Claims Processing Manual).
Besides the obvious proper and accurate claims submission we all strive for, the split/shared billing concept is especially important to grasp, as there is a 15 percent payment differential depending on whether you bill under the NPP’s NPI (85 percent of Medicare’s 80 percent payment), or under the physician’s NPI (100 percent of Medicare’s 80 percent payment).
A split/shared E/M visit is defined by Medicare Part B as a medically necessary visit with a patient in which both the physician and a qualified NPP (who must be in the same group practice or be employed by the same employer) personally perform a substantive portion of the E/M visit face-to-face with the same patient, on the same date of service. A couple of things should be obvious by the definition:
- This billing applies only to E/M encounters, not procedures. In fact, the CMS Manual is explicit that split/shared does not apply to critical care services or procedures.
- Both the NPP and the physician must each personally perform and document their own documentation to support each had a face-to-face encounter with the patient. No “dictated for Dr. Jones,” or a physician signature on a PA’s progress note, is allowed.
We know that CERT audits concentrate on E/M services; therefore, it was probably a matter of time before they came across visits billed under a physician’s NPI because the physician thought the requirements for split/shared had been met. The CERT’s findings? Insufficient documentation to support the dual roles. Specifically, “A split/shared E&M claim was submitted for payment. While the submitted documentation contained a physician’s signature on the NPP’s clinical note, no other documentation was made by the physician supporting that the physician performed a substantive portion of the split/shared E&M service.” This claim was scored an improper payment due to an “insufficient documentation error.”
Source: Medicare Quarterly Provider Compliance Newsletter–Volume 3, Issue 3–April 2013.
When an area of insufficient documentation is identified by the CERT contractor, education and audits by the MACs is usually not far behind. With that in mind, how do we make sure doctors understand the real nature of Split/Shared/E/M visits? We need to get the message out that it takes two persons splitting or sharing a visit, and each documenting and signing his or her own portion of that note, if doctors are to fare well when the inevitable targeted audits begin.
Jean Acevedo, LHRM, CPC, CHC, CENTC has more than 30 years of health care experience. She has a particular expertise in chart audits, compliance & education. Jean has also been an expert witness in civil litigation as well as Federal fraud cases and serves as an Investigative Consultant for the DOJ and FBI.