Peter Davidyock
Expert
Evaluation & Management: Split/Shared E/M
The following information is provided to assist in the appropriate documentation of split/shared E/M inpatient/outpatient hospital services.
When an E/M service is performed in the hospital inpatient/hospital outpatient or emergency department and is shared between a physician and a NPP from the same group practice, the service may be billed as a split/shared E/M service. The split/shared service may be reported to Medicare using either the physician's or the NPP's Unique Physician Identification Number (UPIN), Provider Identification Number (PIN), and National Provider Identifier (NPI) number.
In order to report the service under the physician’s UPIN/PIN/NPI number, the physician must meet multiple requirements. Those requirements are:
•The physician must provide a face-to-face encounter with the patient;
•The physician must document at least one element of the history, exam and/or medical decision making component of the E/M service;
NOTE: It is not sufficient for the NPP to document the physician involvement and then the physician document “seen and agree” or simply countersign. The physician must document what he/she personally performed during the E/M service;
•The physician must legibly sign the medical record (electronic signatures are acceptable) to justify involvement in the patient care; and
•The physician and the NPP must be actively involved in the Medicare Program and have a valid UPIN/PIN/NPI number for reporting purposes.
If any of the above are lacking in the patient’s medical record, then the service may only be reported using the NPP's UPIN/PIN/NPI. Payment will then be made at the appropriate physician fee schedule rate based on the UPIN/PIN/NPI entered on the claim. Please keep in mind that the following services may not be billed as split/shared services:
1. Critical Care services;
2. Procedures; and
3. E/M services performed in the skilled nursing facility (SNF)/nursing facility (NF).
Other requirements that should be considered when billing for Split/Shared E/M services are:
•Any services provided by the NPP must be performed within the scope of his/her practice;
•The E/M service must be “reasonable and necessary” as defined by Title XVIII of the Social Security Act, Section 1862(a)(1)(A);
•The E/M service/level of care should be supported by using both the physician’s and NPP’s documentation;
•The physician service and NPP service may occur jointly or at independent times throughout the day as long as they occur on the same calendar day; and
•The duration of the E/M service should not control the level of care unless the following is documented in the medical record: The total time spent in the encounter;
More than 50% of the time providing the service was spent providing counseling or coordination of care; and a description of the content of the counseling or coordination of care.
If an NPP or a Scribe is used for documenting purposes then the record requires 2 additional entries. One from the physician who performed the service:
Example: I, Dr. John Doe, personally performed the services described in this documentation, as recorded by Jane Smith RN in my presence, and it is both accurate and complete.
(Physician co-signs the medical note)
and one from the NPP/Scribe who recorded the service?
Example: I, Jane Smith RN am scribing for, and in the presence of, Dr. John Doe.
(Name of acting scribe for the physician)
For a split/shared service to be reimbursed by Medicare Part B, the supporting medical records must satisfy the documentation requirements found in the Internet-Only Manual (IOM) references. An inpatient Split/Shared Evaluation and Management (E/M) service is defined by the Centers for Medicare & Medicaid Services (CMS) IOM Publication 100-04, Chapter 12, Section 30.6.1(B), as an E/M service, "...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." Additionally, IOM Publication 100-04, Chapter 12, Section 30.6.13 (H) states that, "A split/shared E/M visit is defined by Medicare Part B payment policy as 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. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service."
Both the physician and the NPP must each personally perform part of the visit, and both the physician and the NPP must document the part(s) that he or she personally performed. When the supporting documentation does not demonstrate that the physician "performed a substantive portion of the E/M visit face-to-face with the same patient on the same date of service" as the portion of service performed by the NPP, a service billed under the physician's Provider Transaction Access Number (PTAN) will be denied.
It is of particular importance to remember that notes documented by the NPP for E/M services performed independently within a facility, and later reviewed and co-signed by the physician, depict neither a scribe situation nor an appropriate split/shared visit. Additionally, "incident to" guidelines do not apply to services in an inpatient setting. In this situation, the service should be billed under the NPP's provider number, and would be reimbursed at the established rate for that provider.
With the IOM requirements in mind, the following are examples of medical record documentation by the physician which would not be considered adequate to support a split/shared visit:
• "I have personally seen and examined the patient independently, reviewed the PA's Hx, exam and MDM and agree with the assessment and plan as written" signed by the physician
• "Patient seen" signed by the physician
• "Seen and examined" signed by the physician
• "Seen and examined and agree with above (or agree with plan)" signed by the physician
• "As above" signed by the physician
• Documentation by the NPP stating "The patient was seen and examined by myself and Dr. X., who agrees with the plan" with a co-sign of the note by Dr. X
• No comment at all by the physician, or only a physician signature at the end of the note
In conclusion, please remember that for a split-shared visit, there must be documentation of the face-to-face portion of the E/M encounter between the patient and the physician. The medical record should also clearly identify the part(s) of the E/M service which were personally provided by the physician, and which were provided by the NPP. In the absence of such documentation, the service may only be billed under the NPP's provider number per CMS IOM Publication 100-04, Chapter 12, Section 30.6.1 (B). This applies to the initial history and physical examination, the discharge summary, and subsequent hospital visits.
Hope this is of benefit to some of you.
Peter
The following information is provided to assist in the appropriate documentation of split/shared E/M inpatient/outpatient hospital services.
When an E/M service is performed in the hospital inpatient/hospital outpatient or emergency department and is shared between a physician and a NPP from the same group practice, the service may be billed as a split/shared E/M service. The split/shared service may be reported to Medicare using either the physician's or the NPP's Unique Physician Identification Number (UPIN), Provider Identification Number (PIN), and National Provider Identifier (NPI) number.
In order to report the service under the physician’s UPIN/PIN/NPI number, the physician must meet multiple requirements. Those requirements are:
•The physician must provide a face-to-face encounter with the patient;
•The physician must document at least one element of the history, exam and/or medical decision making component of the E/M service;
NOTE: It is not sufficient for the NPP to document the physician involvement and then the physician document “seen and agree” or simply countersign. The physician must document what he/she personally performed during the E/M service;
•The physician must legibly sign the medical record (electronic signatures are acceptable) to justify involvement in the patient care; and
•The physician and the NPP must be actively involved in the Medicare Program and have a valid UPIN/PIN/NPI number for reporting purposes.
If any of the above are lacking in the patient’s medical record, then the service may only be reported using the NPP's UPIN/PIN/NPI. Payment will then be made at the appropriate physician fee schedule rate based on the UPIN/PIN/NPI entered on the claim. Please keep in mind that the following services may not be billed as split/shared services:
1. Critical Care services;
2. Procedures; and
3. E/M services performed in the skilled nursing facility (SNF)/nursing facility (NF).
Other requirements that should be considered when billing for Split/Shared E/M services are:
•Any services provided by the NPP must be performed within the scope of his/her practice;
•The E/M service must be “reasonable and necessary” as defined by Title XVIII of the Social Security Act, Section 1862(a)(1)(A);
•The E/M service/level of care should be supported by using both the physician’s and NPP’s documentation;
•The physician service and NPP service may occur jointly or at independent times throughout the day as long as they occur on the same calendar day; and
•The duration of the E/M service should not control the level of care unless the following is documented in the medical record: The total time spent in the encounter;
More than 50% of the time providing the service was spent providing counseling or coordination of care; and a description of the content of the counseling or coordination of care.
If an NPP or a Scribe is used for documenting purposes then the record requires 2 additional entries. One from the physician who performed the service:
Example: I, Dr. John Doe, personally performed the services described in this documentation, as recorded by Jane Smith RN in my presence, and it is both accurate and complete.
(Physician co-signs the medical note)
and one from the NPP/Scribe who recorded the service?
Example: I, Jane Smith RN am scribing for, and in the presence of, Dr. John Doe.
(Name of acting scribe for the physician)
For a split/shared service to be reimbursed by Medicare Part B, the supporting medical records must satisfy the documentation requirements found in the Internet-Only Manual (IOM) references. An inpatient Split/Shared Evaluation and Management (E/M) service is defined by the Centers for Medicare & Medicaid Services (CMS) IOM Publication 100-04, Chapter 12, Section 30.6.1(B), as an E/M service, "...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." Additionally, IOM Publication 100-04, Chapter 12, Section 30.6.13 (H) states that, "A split/shared E/M visit is defined by Medicare Part B payment policy as 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. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service."
Both the physician and the NPP must each personally perform part of the visit, and both the physician and the NPP must document the part(s) that he or she personally performed. When the supporting documentation does not demonstrate that the physician "performed a substantive portion of the E/M visit face-to-face with the same patient on the same date of service" as the portion of service performed by the NPP, a service billed under the physician's Provider Transaction Access Number (PTAN) will be denied.
It is of particular importance to remember that notes documented by the NPP for E/M services performed independently within a facility, and later reviewed and co-signed by the physician, depict neither a scribe situation nor an appropriate split/shared visit. Additionally, "incident to" guidelines do not apply to services in an inpatient setting. In this situation, the service should be billed under the NPP's provider number, and would be reimbursed at the established rate for that provider.
With the IOM requirements in mind, the following are examples of medical record documentation by the physician which would not be considered adequate to support a split/shared visit:
• "I have personally seen and examined the patient independently, reviewed the PA's Hx, exam and MDM and agree with the assessment and plan as written" signed by the physician
• "Patient seen" signed by the physician
• "Seen and examined" signed by the physician
• "Seen and examined and agree with above (or agree with plan)" signed by the physician
• "As above" signed by the physician
• Documentation by the NPP stating "The patient was seen and examined by myself and Dr. X., who agrees with the plan" with a co-sign of the note by Dr. X
• No comment at all by the physician, or only a physician signature at the end of the note
In conclusion, please remember that for a split-shared visit, there must be documentation of the face-to-face portion of the E/M encounter between the patient and the physician. The medical record should also clearly identify the part(s) of the E/M service which were personally provided by the physician, and which were provided by the NPP. In the absence of such documentation, the service may only be billed under the NPP's provider number per CMS IOM Publication 100-04, Chapter 12, Section 30.6.1 (B). This applies to the initial history and physical examination, the discharge summary, and subsequent hospital visits.
Hope this is of benefit to some of you.
Peter
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