Share or Split E/M Services?
Under certain conditions, a physician and a mid-level provider (MLP)—such as a nurse practitioner, physician assistant, certified nurse specialist, or certified nurse-midwife—each may provide a portion of an evaluation and management (E/M) service for a Medicare patient, and the service may be reported under the physician’s provider number. This allows for optimum reimbursement (physicians receive 100 percent of the physician fee schedule payment for services properly billed, whereas an MLP—billing under her own provider number—receives only 85 percent reimbursement for the same services), while potentially increasing physician productivity.
Sharing Isn’t Always Good
The Centers for Medicare & Medicaid Services (CMS) policy (Medicare Claims Processing Manual, chap. 12, sec. 30.6.13.H) defines a shared visit as “a medically necessary encounter with a patient where the physician and a qualified MLP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service.”
The rules for billing such shared/split visits depend on the setting and the services rendered. Several types of services may never be shared.
Consultation services (99241-99245, 99251-99255) may never be shared (Medicare Claims Processing Manual, chap. 12, sec. 30.6.10.A); however, a qualified MLP acting within her state scope of practice may report a consultation under her own provider number if all the requirements of a consultation are met.
Critical care services (99291-99292) may not be shared. The Medicare Claims Processing Manual (chap. 12, sec. 30.6.12.E.2) specifies, “Unlike other E/M services where a split/shared service is allowed the critical care service reported shall reflect the evaluation, treatment and management of a patient by an individual physician or qualified non-physician practitioner and shall not be representative of a combined service between a physician and a qualified MLP.”
Once again, a qualified MLP may provide critical care if she is acting within scope of practice and meets all other requirements, but such services are not shared with a physician and are billed under the MLP’s own provider number. Services that do not meet these requirements are reported using the appropriate subsequent hospital care code (99231-99233). (See also Medicare transmittal 1530, change request (CR) 5993, www.cms.hhs.gov/Transmittals/downloads/R1530CP.pdf.)
Services provided in a skilled nursing facility (SNF) or nursing facility (NF) may not be shared (ibid. sec. 30.6.13.H).
Procedures may never be shared (ibid. sec. 30.6.13.H).
Here’s the Time to Split
CMS guidelines (ibid. sec. 30.6.13.H) specifically allow split/shared visits for the following services:
- Hospital inpatient
- Hospital outpatient
- Hospital observation
- Emergency department (ED)
- Hospital discharge
- Office and non facility clinic visits
- Prolonged visits associated with any of the above E/M services
As an additional requirement to bill a shared visit, the physician and the qualified MLP must be in the same group practice or be employed by the same employer. For example, an MLP sees a hospital inpatient in the morning and a physician follows with a later face-to-face visit with the patient on the same day. If the MLP is a hospital employee, but the physician is not, the service cannot be “shared.”
In the hospital setting (inpatient, outpatient, or ED), a shared visit may be reported under the physician’s provider number as long as the physician provides any face-to-face portion of the E/M encounter with the patient. If the physician does not see the patient face-to-face (for instance, if the physician only reviewed the patient’s medical record), the service must be reported under the MLP’s provider number (ibid. sec. 30.6.1.B).
For example, a patient reports to the ED with fever. An MLP meets with the patient, gathering a detailed history and taking an expanded problem-focused exam. The ED physician then sees the patient to gather additional history and perform a detailed exam. He orders a chest X-ray, writes a prescription for an antibiotic, and suggests the patient follow-up with an infectious disease specialist. The MLP’s and MD’s notes, added together, would warrant a shared visit at the appropriate level (such as 99283 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity.).
In all cases, documentation should substantiate the shared nature of the visit. For example, the medical record should
- Identify both providers (the MD and MLP);
- Link the MD’s notes to the MLP’s;
- Include legible signatures from both providers; and
- Confirm that the MD performed an E/M element face-to-face with the patient.
The record also should illustrate clearly that both providers saw the patient face-to-face. If the physician merely reviewed records and/or tests, or discussed the case with the MLP without seeing the patient face-to-face, the visit is not shared.
To report a shared visit under the physician’s provider number in the office or clinic setting, the service must meet all incident-to requirements, as described in the Medicare Benefit Policy Manual, chap. 15, sec. 60.0-60.4.C. To meet these requirements, service or supplies must be:
- Provided in the office or clinic setting. (Incident-to E/M visits provided in a facility setting are not payable under the Physician Fee Schedule for Medicare Part B.);
- An integral, although incidental, part of the physician’s professional service in the course of diagnosis or treatment of an injury or illness;
- Commonly rendered without charge, or included in the physician’s bill (see sec. 60.1A, “Where supplies are clearly of a type a physician is not expected to have on hand in his/her office or where services are of a type not considered medically appropriate to provide in the office setting, they would not be covered under the incident to provision.”); and
- Furnished by the physician or by auxiliary personnel under the physician’s direct supervision (see sec. 60.1B, “Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.”).
“A service or supply could be considered to be ‘incident to’ when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflect his/her active participation in and management of the course of treatment” (Medicare Benefit Policy Manual, chap. 15, sec. 60.1.B). In other words, when billing incident-to, the MLP can see only existing patients with a physician-established care plan.
“If ‘incident to’ requirements are not met for the shared/split E/M service, the service must be billed under the MLP’s UPIN/PIN, and payment will be made at the appropriate physician fee schedule payment,” confirms the Medicare Claims Processing Manual, chap. 12, sec. 30.6.1.B.
Although incident-to visits are common in the office, a shared incident-to service would be relatively rare. As an example of such a service, an MLP sees an existing patient under the physician’s care plan. The MLP discovers a new problem not covered under the care plan, and calls in the physician to treat the new problem. In such a case, you would bill both providers’ services as a shared E/M visit under the physician’s provider number.
If the qualified MLP provides the workup for the patient’s new problem herself, the visit would not qualify as incident-to physician services, and would be reported under the MLP’s own provider number.
Keep in mind that incident-to rules only apply to Medicare. You will want to confirm with your top payers how they want these types of services to be handled.