# split/shared vs incident to



## cwells (Aug 18, 2014)

In the office setting does split/shared and incident to mean two different things?

Example #1: the PA and the physician are both seeing an established patient with an established problem, which to me, makes this a split/shared visit. My question: does the physician have to document the portions of the visit he personally performed?

Example #2: the PA sees an established patient in which the physician has formulated a treatment plan. The PA is able to bill under the physician's name and number becuase "incident to" has been met?

It is this part that is confusing me:

Office/Clinic Setting ? In the office/clinic setting when the physician performs the E/M service, the service must be reported using the physician?s NPI. When an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed ?incident to? if the requirements for ?incident to? are met and the patient is an established patient. If ?incident to? requirements are not met for the shared/split E/M service, the service must be billed under the non-physician?s NPI, and payment will be made at the appropriate physician fee schedule payment.[/SIZE]


So is that saying the physician does not need to document the key portions of the visit he performed?


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## mitchellde (Aug 18, 2014)

The split visit is lined out for you in CR1776.  The difference is for incident to the provider must have seen the patient previous for the exact same reason and there must be a plan of care in the chart that th NPP is following.  If the NPP changes anything in the plan or looks at a new complaint then it is no longer incident to.  A shared visit cannot be a new patient but can be an est patient that the NPP session for part of the encounter and the provider sees for part and provides the MDM.  The provider must document his portion of the encounter.  So say a visit with the NPP started as incident to but the patient has a new problem to be reviewed, the NPP can have the provider come in and evaluated the new problem (document) and the entire encounter goes together and is billed under the physician.


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## Tonyj (Aug 18, 2014)

cathy.wells@alnmm.com said:


> In the office setting does split/shared and incident to mean two different things?
> 
> Example #1: the PA and the physician are both seeing an established patient with an established problem, which to me, makes this a split/shared visit. My question: does the physician have to document the portions of the visit he personally performed?
> 
> ...



Split/shared services are for inpatient encounters. The physician must document at least 1 element of the key portion. 

"Incident to" refers to outpatient services. Whereas, as long as the physician is supervising then "agree with NP, PA..." is sufficient.


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## mitchellde (Aug 18, 2014)

Tonyj said:


> Split/shared services are for inpatient encounters. The physician must document at least 1 element of the key portion.
> 
> "Incident to" refers to outpatient services. Whereas, as long as the physician is supervising then "agree with NP, PA..." is sufficient.


Tony, where did you get this definition from?  There is nothing in split shared that restricts it to inpatient, and incident to is used only in the physician office setting never facility inpatient or outpatient.


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## CatchTheWind (Aug 18, 2014)

I agree with Debra.  

1) Per Medical Economics at http://medicaleconomics.modernmedic...ting-sharedsplit-visits-correctly-1?page=full : 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)

Shared/split visits are not allowed:
?In a skilled nursing facility or nursing facility setting
?For consultation services [for those payers that pay for consultations]
?For critical care services
?For procedures
?In a patient?s home or domiciliary site.

2)  Incident-to services may _*only*_ be performed in a physician's office or patient's home.

3) I would like to modify Tonyj's statement (regarding incident to) that "as long as the physician is supervising then 'agree with NP, PA...' is sufficient.' This is correct _*only *_ if the PA is seeing an established patient with an established problem and an established (by the physician) plan of care.  And, in fact, as long as those conditions are met, the statement of agreement is not even required.


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## Tonyj (Aug 19, 2014)

mitchellde said:


> Tony, where did you get this definition from?  There is nothing in split shared that restricts it to inpatient, and incident to is used only in the physician office setting never facility inpatient or outpatient.



Wow. I love this forum. I stand corrected. I know "incident to" is only used in the physician office setting. But, I needed to reread what I read about split shared services several more times to see that it doesn't just apply to inpatient services. But, now I'm concerned about the "office setting" for split shared services. Below is an excerpt from Novitas explaining split shared services. Which initially is why I associated S/S with inpatient physician services only. I didn't include office and non facility clinic visits. 

If a patient is seen in the office, would the guidelines be applicable only in accordance with the documentation provided? ie "if MD dictates key portion=split shared" or "if NP sees patient under supervision of MD=incident to"?

The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and non facility clinic visits, and prolonged visits associated with these E/M visit codes). The split/shared E/M policy does not apply to critical care services or procedures.


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## cwells (Aug 19, 2014)

Thanks to all that answered.....I guess I am still getting hung up on the statement: shared visits are _considered_ to be performed incident to.

If both the PA and physician are always seeing an established patient then they both need to document? correct?

Basically what it is saying is a shared visit is when both providers see the patient, and both document their portion? But if the PA sees the patient they can bill under the physician name and number if incident to guidelines have been met?

You would probably only expect to see a shared visit when the plan changes or there is a new problem? correct? Not every visit being shared?

Thanks so much 
Cathy


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## cwells (Aug 20, 2014)

Would you agree with this answer?

They must meet the "incident to" guidelines first to even consider billing as a shared visit.  So if it is a new problem or a significant change in a chronic problem where the plan of care has not been established you have not  met incident to guidelines.  It is very rare in the clinic setting that shared care will apply.  If it meets the incident to guidelines, you would just bill incident to.

That makes sense, but then the physician doesn't have to document if he is seeing the patient?

Correct.  If they meet incident to then the physician does not have to document unless your state has physician signature requirements for NPP's.


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## CatchTheWind (Aug 25, 2014)

I understand it just as you do.


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## mitchellde (Aug 25, 2014)

A shared visit does not have to meet incident to.  The patient must be established and both the NPP and the physician must see the patient face to face and write their own note.  If the visit is incident to and the patient has a new complaint or the treatment needs to be changed then the physician can step into the room and evaluate the patient, write a separate note and the visit be billed as a shared encounter.


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## CatchTheWind (Aug 26, 2014)

Per the Medicare Claims Processing Manual:  "EXAMPLES OF SHARED VISITS: In an 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 UPIN/PIN."

What I understand from this is that incident to requirements don't have to be met in order to bill a shared visit, but they do have to be met in order to bill a shared visit under the PA's NPI.


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