Pain Management Coding Alert

Reader Question:

Remember Different Rules for Incident-to, Split/Shared Visits

Published on Fri Jun 30, 2017

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Question: Can you please explain the difference between a split/shared evaluation and management (E/M) visit and an incident-to visit?

North Dakota Subscriber

Answer: When a physician and a non-physician practitioner (NPP) work together to provide an evaluation and management (E/M) service, the situation could be considered either an incident-to service or split/shared visit.

Important: Medicare, and other payers that follow Medicare’s guidelines, are the only payers who follow incident-to and split/shared visit rules.

Split/shared E/M visit: A split/shared E/M visit is “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,” according to the Medicare Claims Processing Manual.

Other characteristics of split/shared visits E/M include the following, per the Medicare Claims Processing Manual:

The split/shared visit must involve all or some portion of the history, exam, or medical decision making components of an E/M service.
The physician and NPP must be in the same group practice or work for the same employer.
Only report a split/shared E/M visit to selected E/M visits and settings such as hospital-based encounters like the inpatient, observation, and ED. You can also report split/shared for services that take place in hospital outpatient departments or provider-based clinics.
Split/shared visits are not appropriate for critical care services, consultation services, new patient office visits, or in the skilled nursing facility/nursing facility settings.

Incident-to Services: MLN^® Matters SE0441 defines incident-to services as “services that are furnished incident-to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home.”

According to MLN^® Matters SE0441, other characteristics of incident-to services include:

The physician must perform incident-to services in the office as an integral part of the patient’s normal course of treatment that the physician planned when he personally performed the initial service.
The physician must remain actively involved in the patient’s course of treatment.
The physician must be present in the office suite to offer assistance, if needed.
The physician must bill the incident-to service under his ID or to whatever other legal entity that bills for the service.

Remember: As always, the medical documentation should support all of the criteria for an incident-to service. “Incident-to” services don’t require two notes; shared/split visits do.