Are you Documenting Shared/Split Visits Correctly?

Q: I am one of several specialist physicians who recently joined a large hospital organization.  We utilize our midlevel providers, physician assistants (PAs) and nurse practitioners (NPs), extensively in our practice, both in the hospital and in the office. At the hospital, they are normally the first to see our patients. The physicians see the patient during rounding, document that they agree with the midlevel’s findings, and sign off on the note. We bill these visits under the physician’s PIN (Provider Identification Number). Is this correct?

We utilize our PAs in a similar fashion in the office. They initiate the visits for new and established patients, document the visits, and write the plans of care. The physician then sees the patient and signs off on the plan of care. Can we bill these visits under the physician’s PIN?

Our organization’s compliance team has told us that we are not billing these visits appropriately. How should we bill these visits?

A: Non-physician practitioners (NPPs), PAs and NPs are increasingly being relied upon in medical practices and hospitals because it is a good utilization of resources. However, you do need to thoroughly understand the intricacies of incident-to and shared/split billing practices in order to bill these visits appropriately. While there are some similarities in these two billing scenarios, we will address each individually because there are distinct differences that need to be understood. We will cover the shared/split billing guidelines in today’s column, and will detail incident-to requirements in next month’s column.

Shared/split visits

Simply stated, shared/split visits are Evaluation and Management (E/M) visits that are “shared” or “split” between a physician and a NPP, such as a NP, PA, clinical nurse specialist or certified nurse-midwife. If the documentation meets the requirements the visit can be billed under the physician’s PIN, as opposed to the NPP’s PIN. 

So why does it make a difference whether you bill a visit under the physician’s PIN versus the NPP’s PIN?   Medicare allows 100% of the Medicare fee schedule amount for coverable services submitted by a physician. When services are submitted under a NPP’s PIN, Medicare allows only a percentage of the physician fee schedule amount. (The percentage is 85% for physician assistants, nurse practitioners, and clinical nurse specialists.) If the documentation does not meet the guidelines, the service would need to be billed under the NPP’s PIN.

With varying compensation models for physicians and NPPs, correct billing of these services is important so that salaries (and perhaps bonuses) are administered appropriately.

According to the Centers for Medicare and Medicaid Services (CMS), shared/split visits are applicable for services rendered in the following settings:

• Hospital inpatient or outpatient

• Emergency department

• Hospital observation

• Hospital discharge

• Office or clinic (when “incident-to” requirement are met – see next month’s article for further information)

Shared/split visits are not allowed:

• In a skilled nursing facility or nursing facility setting

• For consultation services

• For critical care services

• For procedures

• In a patient’s home or domiciliary site.

Note regarding consultations: Although Medicare does not reimburse for consultation services, the guidelines apply to those carriers who do. For Medicare, an initial inpatient or outpatient code should be billed instead of a consultation code, and shared/split guidelines would apply.

Shared/Split visits are defined by CMS in IOM Publication 100-04, Chapter 12, Section 30.6.1(B) as an E/M service "shared between a physician and a NPP from the same group practice, and the physician provides any face-to-face portion of the E/M encounter with the patient."

The publication additionally states, "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 service must be within the NPP’s scope of practice as defined by the state law where he or she practices, and it must be performed in collaboration with a physician.

So, what are the documentation requirements for a shared/split visit?  These are the key elements that must be met:

• A shared/split visit can only be utilized if the NPP and physician are from the same group practice, including the same specialty. 

• The NPP and physician must both perform and document their face-to-face encounter with the patient. 

• The portion of the E/M service performed and documented by both the NPP and physician must be substantive, which includes part or all of the history, exam or medical decision making.

Case in point

Let’s apply these guideline requirements to the example in our question, which states, “The physicians see the patient during rounding, document that they agree with the midlevel’s findings, and sign off on the note. “ 

In this example, the physician is only documenting that he/she agrees with the findings that the NPP has already documented. The documentation does not show that the physician had face-to-face contact with the patient or that he/she performed any of the history, exam or medical decision making elements. The guidelines require that there must be documentation of the face-to-face portion of the E/M encounter between the patient and the physician. The medical record should clearly identify the part(s) of the E/M service that were personally provided by the physician and those that were provided by the NPP.

Note:  The physician must personally document his/her involvement in the patient’s care and cannot leave his/her documentation of the visit to the NPP. 

Local Medicare carrier clarifications

Check with your local Medicare carrier to ensure what specific guidelines have been clarified in more detail regarding shared/split documentation. Wisconsin Physician Services (WPS), for example, gives the following examples, based on the IOM Publication, that would not adequately meet the shared/split visit requirements:

• "I have personally seen and examined the patient independently, reviewed the PAs history, exam and medical decision making and agree with the assessment and plan as written" signed by the physician

• "Patient seen" signed by the physician

• "Seen and examined" signed by the physician

• "Seen and examined and agree with above (or agree with plan)" signed by the physician

• "As above" signed by the physician

• Documentation by the NPP stating "The patient was seen and examined by myself and Dr. X., who agrees with the plan" with a co-sign of the note by Dr. X

• No comment at all by the physician or only a physician signature at the end of the note.

Commercial payers

Check with your commercial carriers to see if they recognize the shared/split visit guidelines, specifically those carriers who credential NPPs. For carriers who do not credential NPPs, the shared/split visit guidelines would not apply, and all NPP visits would need to be billed under the physician’s PIN. 

In a future article, incident-to guidelines will be addressed which are applicable to physician office visits.