Inpatient Split/Shared Evaluation and Management (E/M) Services

Current review of medical records indicates an increasing number of Initial and Subsequent Hospital, as well as Emergency Department services, being billed as split/shared visits between the billing physician and a Non Physician Practitioner (NPP) from the same group practice. The purpose of this article is to provide guidance on the appropriate documentation of split/shared services.

For a split/shared service to be reimbursed by Medicare Part B, the supporting medical records must satisfy the documentation requirements found in the Internet-Only Manual (IOM) references. An inpatient Split/Shared Evaluation and Management (E/M) service is defined by the Centers for Medicare & Medicaid Services (CMS) IOM Publication 100-04, Chapter 12, Section 30.6.1(B), as an E/M service, "...shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient." Additionally, IOM Publication 100-04, Chapter 12, Section 30.6.13 (H) states that, "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."

Both the physician and the NPP must each personally perform part of the visit, and both the physician and the NPP must document the part(s) that he or she personally performed. When the supporting documentation does not demonstrate that the physician "performed a substantive portion of the E/M visit face-to-face with the same patient on the same date of service" as the portion of service performed by the NPP, a service billed under the physician's Provider Transaction Access Number (PTAN) will be denied.

It is of particular importance to remember that notes documented by the NPP for E/M services performed independently within a facility, and later reviewed and co-signed by the physician, depict neither a scribe situation nor an appropriate split/shared visit. Additionally, "incident to" guidelines do not apply to services in an inpatient setting. In this situation, the service should be billed under the NPP's provider number, and would be reimbursed at the established rate for that provider.

With the IOM requirements in mind, the following are examples of medical record documentation by the physician which would not be considered adequate to support a split/shared visit:

  • "I have personally seen and examined the patient independently, reviewed the PA's Hx, exam and MDM 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

In conclusion, please remember that for a split shared visit, 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 also clearly identify the part(s) of the E/M service which were personally provided by the physician, and which were provided by the NPP. In the absence of such documentation, the service may only be billed under the NPP's provider number per CMS IOM Publication 100-04, Chapter 12, Section 30.6.1 (B). This applies to the initial history and physical examination, the discharge summary, and subsequent hospital visits.

Review CMS IOM PublicationsLink to external site, for more in depth information.

Page Last Updated: Thursday, 15-Dec-2011 12:04:07 CST