Pain Management Coding Alert

Question: Can you please explain the difference between a split/shared evaluation and management (E/M) visit and an incident-to visit?

North Dakota Subscriber

Answer: When a physician and a non-physician practitioner (NPP) work together to provide an evaluation and management (E/M) service, the situation could be considered either an incident-to service or split/shared visit.

Important:  Medicare, and other payers that follow Medicare’s guidelines, are the only payers who follow incident-to and split/shared visit rules.

Split/shared E/M visit: A split/shared E/M visit is “a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service,” according to the Medicare Claims Processing Manual.

Other characteristics of split/shared visits E/M include the following, per the Medicare Claims Processing Manual:

• The split/shared visit must involve all or some portion of the history, exam, or medical decision making components of an E/M service.
• The physician and NPP must be in the same group practice or work for the same employer.
• Only report a split/shared E/M visit to selected E/M visits and settings such as hospital-based encounters like the inpatient, observation, and ED. You can also report split/shared for services that take place in hospital outpatient departments or provider-based clinics.
• Split/shared visits are not appropriate for critical care services, consultation services, new patient office visits, or in the skilled nursing facility/nursing facility settings.

Incident-to Services: MLN^® Matters SE0441 defines incident-to services as “services that are furnished incident-to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home.”

According to MLN^® Matters SE0441, other characteristics of incident-to services include:

• The physician must perform incident-to services in the office as an integral part of the patient’s normal course of treatment that the physician planned when he personally performed the initial service.
• The physician must remain actively involved in the patient’s course of treatment.
• The physician must be present in the office suite to offer assistance, if needed.
• The physician must bill the incident-to service under his ID or to whatever other legal entity that bills for the service.

Remember: As always, the medical documentation should support all of the criteria for an incident-to service. “Incident-to” services don’t require two notes; shared/split visits do.

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