Inpatient Compliance: Split-Shared Services

In the inpatient setting, a physician can combine his or her documentation with that of a non-physician provider (N.P.P.) to support an E and M service while billing the resulting code under the physician. This is called a “split-shared” service and allows physicians to bill at 100% of the fee schedule rate even though some of the work was done by the N.P.P.. If the N.P.P. were to bill for such a service alone, he or she would typically be paid at 85% of the fee schedule rate.

Last week’s audit tip provided guidance on a similar billing policy, incident-to services, which allow N.P.P.s to bill under physicians in the outpatient office setting. Split-shared visits are the inpatient counterpart to incident-to services, but have less restrictive requirements.

Let’s take a look at split-shared visits starting with the official definition from C.M.S.. Split-shared services are medically necessary E and M visits where a physician and an N.P.P. each perform a “substantive” face-to-face portion of the encounter with a patient on the same date of service.

The key to supporting a visit as being split-shared is this term: “substantive.” C.M.S. defines it as meaning at least some portion of the history, exam, and medical decision-making components of the E and M service. Note: While both the physician and non-physician need to do a “substantive” portion of the service, the guidelines make it clear that the non-physician can do the majority of the work, freeing up the physician to perform surgery or see more complex patients. The service still ends up being billed under the physician’s identifier without any payment reduction that would normally hit non-physician billed services.

No limit on N.P.P. decisions

Unlike incident-to services, split-shared services do not require that a physician first establish a plan of care that the non-physician must follow in treating the patient. Instead, the N.P.P. may adjust the plan as he or she sees fit and the physician may agree with the plan or modify it.

However, the physician cannot simply sign off on the N.P.P.’s note. Merely having the physician write “seen and agree” and signing does not qualify the service to be billed under the physician. The physician must document at least some element of the history or exam separate from what the N.P.P. documents in order to satisfy the “substantive” language cited above.

Also, split-shared services require a face-to-face encounter between the patient and both the physician and non-physician. The physician must physically see the patient to bill a split-shared visit with the N.P.P..

Note that only E and M services can be “split” or “shared” which means that minor procedures such as steroid injections cannot be. Under incident-to guidelines, procedures could be billed by the physician and performed the N.P.P..

Eligible E and M codes

This is the list of services that can be split-shared between a physician and non-physician in the inpatient setting:

• Hospital inpatient: (9-9-2-2-1 through 9-9-2-3-3)

• Hospital outpatient: (9-9-2-1-8 through 9-9-2-2-0)

• Hospital observation: (9-9-2-1-7 through 9-9-2-2-6)

• Emergency department: (9-9-2-8-1 through 9-9-2-8-8)

• Hospital discharge: (9-9-2-3-8 and 9-9-2-3-9)

• Prolonged visits related to the above services: (9-9-3-5-4 through 9-9-3-6-5)

There are also restrictions that apply to split-shared services:

• Consult services, 9-9-2-4-1 through 9-9-2-4-5 cannot be split-shared.

• Any E and M service furnished in a skilled nursing facility or nursing facility cannot be split-shared.

• Any E and M service furnished in a patient’s home or domicile cannot be split-shared.

The ‘who’ and ‘where’ for split-shared services

Non-physician providers and physicians who are employed by the same entity, or who are part of the same group practice, may perform split-shared services. Typically for E.N.T. physicians, either a nurse practitioner or physician assistant would be the N.P.P. used.

Split-shared services are limited to facility-based settings, including the hospital inpatient and outpatient settings. Remember: Services furnished in the hospital outpatient (P.O.S. 22) will result in two bills being generated for Medicare patients. A professional fee is billed under Part B, while a facility fee is billed under Part A. This means incident-to guidelines do not apply to P.O.S. 22, but split-shared guidelines do.

Properly documenting split-shared services

Unlike with incident-to services, supervision does not apply to split/shared services. The physician and N.P.P. do not have to see the patient at the same time. In fact, typically the N.P.P. sees the patient first and creates a note which the physician then adds his or her “substantive” portion to after seeing the patient later.

The same documentation requirements for other services also apply to split-shared services. In addition, billing an E AND M service as split-shared also has a very important and unique requirement. Specifically:

• Both the physician and non-physician must document in the medical record what they personally contributed to the encounter. Tip: For better charge capture, both providers should include a line such as “patient seen and examined by me.” The physician can also include lines such as “agree with note by non-physician” to make it even more clear that the visit included split-shared face-to-face time with the patient.

• The combined documentation must support the overall combined level of service of the E and M visit.

• While auxiliary staff can record the review of systems, past medical, family history, and social history, the physician and non-physician must personally review this documentation and confirm and/or supplement it in their combined medical record.

• If the non-physician has a face-to-face encounter with the patient but the physician does not, then the E and M encounter must be billed only under the non-physician’s name and identifier.

• Both the physician and non-physician must date and legibly sign their corresponding portions of the note.

Example: The physician’s portion of the note should be clear about physician involvement: “I saw and evaluated the patient. I reviewed with the nurse practitioner’s note and agree, in addition I believe follow-up with the primary care doctor is warranted. A follow-up visit should be scheduled in two weeks."

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