Medical Practice Consultant Group

(2008-05-09) Update:

EVER WONDER HOW TO BILL FOR SPLIT/SHARED VISITS?

After spending so much time working with mid-level practitioners around the country in both inpatient and outpatient hospital settings it became obvious to me that there is a lot of misunderstanding regarding how Split/Shared Visits work. A lot of articles focus on "Incident-To" so I thought I would focus on just Split/Shared Visits. After hearing the fact a majority of providers are wanting to bill for everything under the sun when their mid-levels are performing services, I felt it was important to draft this article to give authoritative information to ensure compliance throughout hospitals and physician groups using these services.

What is a Split/Shared Visit

(A split/shared visit is a medically necessary encounter with a patient, where the physician and a qualified NP/PA each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service).

Regarding Medicare back in 2007 there were a lot of clarifications provided regarding Split/Shared Visits and "Incident-To". A whole host of services cannot be billed as a Split/Shared Visits and need to be billed under the NP or PA’s number only or if the physician provides the entire service then it can be billed under their number. The guidelines with other carriers such as the Blues or Cigna, etc.., may be a bit more relaxed than Medicare but this will need to be reviewed very carefully based upon individually negotiated contracts.

NP’s & PA’s can act as a scribe, meaning they can go and gather information, but the note cannot state the patient was seen by Dr. X. and J. Clark, NP. The doctor then normally signs off on the note and gives a brief statement such as “have personally met with the patient and agree with treatment plan”. This will not fly. The physician must provide the key elements of the History, Exam and Establishment of the treatment plan.

Split/shared visits are allowed in these settings only:

Office/Clinic (with "incident to" requirements met.)
•Hospital Inpatient/Outpatient
•Emergency Department
•Hospital Observation
•Hospital Discharge

Split/shared visits are not allowed in the following areas:
•SNF/NF setting
•Consultation services
•Critical Care services
•Procedures
•Patients Home and Domiciliary sites

These are the general requirements for Split/Shared Visits:

The service provided must be reasonable and medically necessary, must be within the NP's/PA’s scope of practice as defined in state law where he/she practices; and performed in collaboration with a physician. The physician & NP/PA must be from the same group practice OR employed by the same employer. Physician must provide any face-to-face portion of the E/M encounter with the patient.

NOTE: (If physician only participated in the service by reviewing the patient's medical record, then service may only be billed under the PA’s or NP's UPIN/PIN.) In the office and non-facility clinic setting the "incident-to" rules apply, so it must always be an established patient.

In hospital settings (inpatient, outpatient, and ED) "incident-to" rules do not apply, and therefore there is no distinction between new and established status in inpatient and ED settings. It is NOT sufficient for MD to note "seen and agree" or simply countersign; he/she must specifically document what he/she has personally done.

This should clarify the changes that have been made in the Shared /Split visits.

By: Judy Clark, ARNP