Evaluation & Management (E/M) Contractor Decisions: Split/Shared E/Ms

Recent review of medical records has shown that there may be some confusion concerning what documentation is necessary when performing and billing for Split/Shared E/Ms Services. The following information is provided to assist physicians/Non-Physician Practitioners (NPPs) in the appropriate documentation of split/shared E/M 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:

  • physician must provide a face-to-face encounter with the patient
  • physician must document at least one element of the history, exam and />or medical decision making component of the E/M service
  • Is not sufficient for the physician to simply document “seen and agree” or simply countersign. The physician must document what he/she personally performed during the E/M service;
  • physician must legibly sign the medical record to justify his involvement in the patient care; and
  • 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).

If the E/M service is provided in the office/clinic setting and the E/M service is a shared/split encounter between the physician and the non-physician practitioner (NP, PA, CNS or CNM), then the service is considered to have been performed “incident to”, if the requirements of “incident to” are met, e.g., the physician has to do the initial evaluation and periodic evaluations to show that he or she is still involved in the case.

If "incident to" requirements are met, then the service can be billed under the physician’s UPIN/PIN/NPI. If they are not met, then the service must be billed under the NPP’s UPIN/PIN/NPI. Additional information on “incident to” requirements can be found online. Again, payment will be made at the appropriate physician fee schedule payment.

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
  • E/M service must be “reasonable and necessary” as defined by Title XVIII of the Social Security Act, Section 1862(a)(1)(A)
  • E/M service/level of care should be supported by using both the physician’s and NPP’s documentation
  • 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
  • duration of the E/M service should not control the level of care unless the following is documented in the medical record: o total time spent in the encounter; o More than 50% of the time providing the service was spent providing counseling or coordination of care. o Description of the content of the counseling or coordination of care
> Provided below are some examples of split/shared visits:
  • If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service.
  • 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/NPI.
Please refer to the following references for additional information on split/shared services: