Oncology & Hematology Coding Alert

Question: Our oncologist and our PA evaluated a patient together in the hospital and the office manager said to report it as an incident to service, but I thought incident-to wasn’t applicable in the hospital setting. Can you advise?

Codify Subscriber

Answer: You are correct. The concept of incident-to is only applicable to non-institutional settings (those other than a hospital or skilled nursing facility). However, your doctor and your PA may have performed what’s known as a “split/shared E/M visit,” which is allowed in most hospital inpatient and outpatient departments.

What it means: A split/shared E/M visit occurs when the physician and a qualified mid-level provider each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. When your clinician and NPP perform split/shared E/M services for a patient in a hospital, incident to rules do not apply.

How to bill: When such an E/M visit is 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, the service may be billed under either the physician’s or the NPP’s NPI, CMS says in Transmittal 178. However, if there was no face-to-face encounter between the patient and the physician (e.g., the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPP’s NPI, the agency advises.

When reporting a split/shared visit, you should ensure that there were, in fact, two providers who were involved in providing the service and they were qualified to perform the service. In other words, you will be able to report a split/shared visit if and only if the service involved both a physician and a qualified NPP.

When reporting split/shared visits and incident-to visits, you will need to also see to it that date of service requirements are met. For reporting a visit as split/shared, you have to make sure that both the providers involved in performing the service saw the patient on the same calendar date of service. If your physician saw the patient on one day and your NPP is seeing the patient on another calendar date of service, you would not report the visits in combination as split/shared. Rather, you must consider alternatives to report the encounter(s) based on the supporting progress notes.