Incident To/Shared/Split Billing (Q&As)
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Incident to billing is when a service is provided in an office setting by someone other than the physician. However, if the situation meets the guidelines, the physician may bill Medicare for the service.
Shared/split billing is for services provided in any location when both the physician and a non-physician practitioner (NPP) provide, document, and sign the work they each performed. There must be a face-to-face encounter with both the physician and NPP. The physician can bill the service to Medicare.
Why does this make a difference? Medicare allows 100% of the Medicare fee schedule amount for coverable services submitted by a physician. Medicare allows a percentage of the physician fee schedule amount when services are submitted under an NPP provider number. (The percentage is 85% for physician assistants, nurse practitioners, and clinical nurse specialists.) If the situation does not meet the guidelines, the NPP would bill the services. You can find more information in the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.1.b, and 100-02, Chapter 15, Section 60.
Q1. Can a physician and an NPP perform the discharge visit as shared/split? If they can, who bills for the service? If they cannot, who bills for the service?
A1. A physician and NPP may perform the discharge management services as shared/split. The CMS IOM Publication 100-04, Chapter 12, Section 18.104.22.168, discusses hospital discharge services. Each party must document the work they performed. The documentation must show a face-to-face encounter with the physician. If there is no face-to-face encounter with the physician, the NPP must bill the service using his/her National Provider Identifier (NPI).
Q2. We are a hospital-based Rural Health Clinic (RHC) and have questions on locum tenens, reciprocal, and incident to situations. Where can we take our questions?
A2. You can take your questions to your fiscal intermediary (FI) or Medicare Administrative Contractor (MAC). If WPS Medicare is your FI or MAC, then go to our website and choose Medicare Part A from the left-hand side of our website. Once you accept the Current Procedural Terminology (CPT) license agreement, you can search "Rural Health Clinic" to see the education we have available. If you are not finding an answer to your question, you may choose "Contact Us" at the top of the page.
Q3. We are a physician clinic and our physician has left. We currently have two NPPs providing services. A physician in another office sponsors and supervises the NPPs. Can we bill the NPP services as incident to the physician in the other office?
A3. No. Services provided in the office must meet the incident to requirements, one of which is that the billing provider must be present in the office suite. In the situation you describe, bill the services under the NPI of the NPPs. You can find more information on the incident to requirements in the CMS IOM Publication 100-04, Chapter 12, Section 30.6.1, and 100-02, Chapter 15, Section 60.
Q4. Is it necessary to have the physician sign the medical record when the NPP provides a service incident to the physician? Can just the NPP sign the note?
A4. Medicare does not require the physician to sign the medical record when the NPP provides a service under the incident to guidelines. Physicians would need to look to state regulations and their own comfort level in determining whether they need to sign the note.
Q5. Is it necessary to have the physician sign the medical record when the NPP and the physician provide a shared/split visit? Can the NPP document that the physician agrees?
A5. Under a shared/split visit situation, both parties must document and sign the work they perform. A notation of "seen and agreed" or "agree with above" would not qualify the situation as a shared/split visit because these statements do not support a face-to-face contact with the physician. Only the NPP could bill for the services.
Q6. If the physician is not in the office, but available by phone, can the NPP bill under the incident to guidelines?
A6. No. If the physician is not in the office suite, the service does not qualify under the incident to guidelines. The NPP would bill for the service under his/her provider number.
Q7. Both the physician and the NPP performed part of the Evaluation and Management (E/M) service for the patient. The doctor left the documentation of the visit to the NPP. Is this a shared/split visit?
A7. No. To bill a shared/split visit, both the physician and the NPP must document the work they performed and sign their part of the medical record.
Q8. What are you looking for to prove that the doctor had a face-to-face with the patient for share/split visits?
A8. The doctor must document his/her work and sign the medical record.
Q9. If a PA in orthopedics has the initial encounter with a patient, then the patient meets with the physician the next day and the physician develops a plan of care, can the PA then bill incident to for the encounters after the physician's visit?
A9. The initial encounter is billed under the NPP number. Any subsequent visits after the patient sees the physician may be billed under the physician's provider number only if the situation meets the incident to requirements. See CMS IOM 100-02, Chapter 15, Section 60.
Q10. Can we bill inpatient subsequent visits as a shared/split visit?
A10. Yes. You can bill a shared/split visit only if the visit meets the documentation requirements for facility services. For a shared/split visit, both the MD/DO and the NPP must document and sign the portion of the visit they performed.
Q11. Are nurses able to perform services incident to an NPP when the NPP is present in the office?
A11. The incident to requirements apply to services incident to both the physician and the NPP. A nurse is able to provide a service incident to the NPP when the situation meets all requirements. If the nurse or auxiliary person performs E/M services, use code 99211.
Q12. In the office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. 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 NPI. In the above scenario, when incident to requirements are not met, can the physician bill for the service using only his/her documentation? If not, what is the reasoning. If the physician can bill, can he then use any documented PFSH or ROS if these were documented by the APN/PA? If they in fact perform a shared visit knowing a consult cannot be shared, can the physician then bill a consultation based on his documentation only?
A12. A consultation cannot be performed as a shared/split service. The physician would submit a new or established patient visit as appropriate. In an office setting where the physician and NPP share/split the service, if the incident to requirements are not met, only the NPP can submit the charge. This is based on the CMS IOM Publication 100-04, Chapter 12, Section 30.6.1.
Q13. Since Medicare no longer recognizes the consultation codes, does this mean that the physician and NPP can perform a shared/split visit for the visit resulting from a request from another provider to see the patient?
A13. Yes, Services previously billed as consultation services would now fall under the guidelines of all other E/M services. Therefore, if the services were shared/split between the physician and NPP, both would have to document the services they provided and both would have to sign their documentation.
Q14. If the service performed in the office meets the shared/split billing guidelines but does not meet the incident to requirements in the office, can we still bill under the MD/DO?
A14. No. Shared/split visits in the office must meet the incident to requirements. The NPP must bill for the services under his/her own Medicare number.
Q15. The physician reviews the documentation from the PA, but does not see the patient. Is this a shared/split visit? The PA documents the physician reviews and agrees. Does it make a difference if this is a new or established patient visit charge?
A15. If the physician is not performing any of the E/M services, it is not a shared/split visit. If the service is performed in a facility setting, only the NPP may submit a charge for the service. If the service is performed in an office setting, the physician may submit a charge for the service if the incident to requirements are met. One requirement is that it is the physician who has established the plan of care. Therefore, if the patient is new, only the NPP may bill the service.
Q16. Is there a restriction on the level of procedure codes allowed under the incident to or shared/split guidelines?
A16. There is no restriction on the level of service as long as the situation meets the requirements and the person providing the services can legally perform the services.
Q17. We schedule patients for injections, blood draws and other minor visits before the physician comes into the office. Can we bill for these services under the incident to guidelines?
A17. Medicare pays for services and supplies (including drugs and biologicals) furnished incident to a physician's or other NPP's services, which are commonly included in the physician's bills, and for which payment is not made under a separate benefit category listed in §1861(s) of the Act. One of the requirements of incident to billing is that the physician must provide direct supervision - the physician must be in the office suite. For more information, see the CMS IOM Publication 100-02, Chapter 15, Section 60.
Laboratory tests have their own benefit category as listed in §1861(s) of the act and as such are not subject to the incident to guidelines. Medicare considers a blood draw as part of the Clinical Laboratory services and as such is not subject to the incident to guidelines. You can find more information in the Medicare Learning Network (MLN) Matters Special Edition SE0441.