January 2019

Quality Assurance: How to Report Shared/Split Visits
By John Verhovshek, MA, CPC
For The Record
Vol. 31 No. 1 P. 8

A "shared" or "split" patient visit occurs when both a physician and a qualified nonphysician practitioner (NPP) meet face to face with a Medicare patient on the same date of service. In other words, the work of the physician and the NPP are "combined" into a single evaluation and management (E/M) service.

Shared/split visits may improve a physician's productivity and positively affect patient care, but to take advantage of these benefits, documentation and reporting requirements must be met.

Defining Shared/Split
Medicare Part B payment policy (Medicare Claims Processing Manual, Chapter 12, § 30.6.13.H) defines a split/shared E/M visit 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." The document clarifies that "a substantive portion of an E/M visit" means "all or some portion of the history, exam, or medical decision making key components of an E/M service."

To bill a shared visit, the physician and the qualified NPP must be in the same group practice or work for the same employer (the NPP may be a "leased" employee).

The only NPPs Medicare recognizes as eligible to participate in shared/split visits are nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives. Additionally, services performed by an NPP must be within the NPP's scope of practice, as defined by the state law.

Not Every E/M Service May Be Shared/Split
Only the following select E/M services may be reported as shared/split visits:

• hospital inpatient;
• hospital outpatient;
• hospital observation;
• emergency department;
• hospital discharge;
• office and nonfacility clinic visits; and
• prolonged visits associated with any of the above.

Consultation (99241–99245, 99251–99255), critical care (99291–99292), and nursing facility services may never be reported as shared/split visits.

Rules Differ According to Setting
The requirements to report a shared/split visit depend on the setting in which the service is provided.

In the office or clinic: Per the Claims Processing Manual, Chapter 12, § 30.6.1.B, in the office or clinic setting, shared/split visits must meet all "incident to" requirements.

Medicare requirements for incident-to payment, which are specified in the Medicare Benefit Policy Manual, Chapter 15, Section 60, include the following:

• The service must take place in a "noninstitutional setting," which the Centers for Medicare & Medicaid Services defines as "all settings other than a hospital or skilled nursing facility."

• A Medicare-credentialed physician must initiate the patient's care. If the patient has a new or worsened complaint, a physician must conduct an initial E/M service for that complaint and establish the diagnosis and plan of care. Incident-to services cannot be rendered on the patient's first visit, or if a change to the plan of care occurs. In other words, to meet incident-to requirements, the NPP can see only existing patients with a physician-established plan of care.

• Subsequent to the encounter during which the physician establishes a diagnosis and initiates the plan of care, an NPP may provide follow-up care under the "direct supervision" of a qualified provider. Direct supervision is defined as: "The supervisory physician must remain present within the office suite where the service is being furnished and must be immediately available to furnish assistance and direction throughout the performance of the procedure. The supervisory physician is not required to be present in the room where the procedure is being performed."

• A physician must actively participate in and manage the patient's course of treatment. This requirement typically is defined precisely by the state licensure rules for physician supervision of NPPs (eg, the physician must see the patient every third visit).

• Both the credentialed physician and the qualified NPP providing the incident-to service must be employed by the group entity billing for the service (if the physician is a sole practitioner, the physician must employ the NPP).

• The incident-to service must be the type of service usually performed in the office setting and be part of the normal course of treatment of a diagnosis or illness. The Medicare Benefit Policy Manual specifies, "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."

Note that the "incident-to" rules (like the shared/split visit rules) apply only to Medicare.

In the hospital inpatient, outpatient, and emergency department settings, a shared visit may be reported under the physician's provider number as long as he or she 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 reviews the patient's medical record and discusses the case with the NPP), the service must be reported under the NPP's provider number.

How to Document a Shared Visit
When documenting a shared/split visit, each provider signs and dates their own portion of the visit. Additionally, each provider's documentation should accomplish the following:

• identify both the physician and the NPP involved in the patient care at that encounter;

• link the physician's notes to the NPP's notes;

• confirm that the physician performed at least one E/M element (eg, history, exam, or medical decision making) face to face with the patient; and

• substantiate that both providers saw the patient face to face. If the physician does not see the patient face to face, the visit does not qualify as shared/split.

The Medicare Claims Processing Manual, Chapter 12, § 30.6.1.B, offers the following examples of shared/split visits:

• If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service.

• The NPP performs a portion of an E/M encounter and the physician completes the E/M service in an office setting. If the "incident-to" requirements are met, the physician reports the service. If the "incident-to" requirements are not met, the service must be reported using the NPP's UPIN/PIN.

Complete Payment Depends on Compliance
If all documentation and reporting requirements have been met, report shared/split visits under the physician's provider number, which allows for reimbursement at 100% of the fee schedule amount. If a shared/split visit fails to meet all documentation and reporting requirements, the service must be reported using the qualified NPP's provider number, which results in lower reimbursement (85% of the fee schedule amount).

Note, once again, that the shared/split visit guidance provided in this article is specific to Medicare payers. Private and non-Medicare government payers specify their own guidelines, which may differ (for example, many private payers do not credential NPPs).

— John Verhovshek, MA, CPC, is managing editor of AAPC Publications.