Inpatient Compliance: Split-Shared Services

June 23rd, 2017 - Grant Huang
Categories:   Billing   Home Health|Hospice   Collections  
0 Votes - Sign in to vote or comment.

In the inpatient setting, a physician can combine his or her documentation with that of a non-physician provider (N.P.P.) to support an E and M service while billing the resulting code under the physician. This is called a “split-shared” service and allows physicians to bill at 100% of the fee schedule rate even though some of the work was done by the N.P.P.. If the N.P.P. were to bill for such a service alone, he or she would typically be paid at 85% of the fee schedule rate.

Last week’s audit tip provided guidance on a similar billing policy, incident-to services, which allow N.P.P.s to bill under physicians in the outpatient office setting. Split-shared visits are the inpatient counterpart to incident-to services, but have less restrictive requirements.

Let’s take a look at split-shared visits starting with the official definition from C.M.S.. Split-shared services are medically necessary E and M visits where a physician and an N.P.P. each perform a “substantive” face-to-face portion of the encounter with a patient on the same date of service.

The key to supporting a visit as being split-shared is this term: “substantive.” C.M.S. defines it as meaning at least some portion of the history, exam, and medical decision-making components of the E and M service. Note: While both the physician and non-physician need to do a “substantive” portion of the service, the guidelines make it clear that the non-physician can do the majority of the work, freeing up the physician to perform surgery or see more complex patients. The service still ends up being billed under the physician’s identifier without any payment reduction that would normally hit non-physician billed services.

No limit on N.P.P. decisions

Unlike incident-to services, split-shared services do not require that a physician first establish a plan of care that the non-physician must follow in treating the patient. Instead, the N.P.P. may adjust the plan as he or she sees fit and the physician may agree with the plan or modify it.

However, the physician cannot simply sign off on the N.P.P.’s note. Merely having the physician write “seen and agree” and signing does not qualify the service to be billed under the physician. The physician must document at least some element of the history or exam separate from what the N.P.P. documents in order to satisfy the “substantive” language cited above.

Also, split-shared services require a face-to-face encounter between the patient and both the physician and non-physician. The physician must physically see the patient to bill a split-shared visit with the N.P.P..

Note that only E and M services can be “split” or “shared” which means that minor procedures such as steroid injections cannot be. Under incident-to guidelines, procedures could be billed by the physician and performed the N.P.P..

Eligible E and M codes

This is the list of services that can be split-shared between a physician and non-physician in the inpatient setting:

There are also restrictions that apply to split-shared services:

The ‘who’ and ‘where’ for split-shared services

Non-physician providers and physicians who are employed by the same entity, or who are part of the same group practice, may perform split-shared services. Typically for E.N.T. physicians, either a nurse practitioner or physician assistant would be the N.P.P. used.

Split-shared services are limited to facility-based settings, including the hospital inpatient and outpatient settings. Remember: Services furnished in the hospital outpatient (P.O.S. 22) will result in two bills being generated for Medicare patients. A professional fee is billed under Part B, while a facility fee is billed under Part A. This means incident-to guidelines do not apply to P.O.S. 22, but split-shared guidelines do.

Properly documenting split-shared services

Unlike with incident-to services, supervision does not apply to split/shared services. The physician and N.P.P. do not have to see the patient at the same time. In fact, typically the N.P.P. sees the patient first and creates a note which the physician then adds his or her “substantive” portion to after seeing the patient later.

The same documentation requirements for other services also apply to split-shared services. In addition, billing an E AND M service as split-shared also has a very important and unique requirement. Specifically:

Example: The physician’s portion of the note should be clear about physician involvement: “I saw and evaluated the patient. I reviewed with the nurse practitioner’s note and agree, in addition I believe follow-up with the primary care doctor is warranted. A follow-up visit should be scheduled in two weeks."

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Preview the PDGM Calculator for Home Health Today
December 4th, 2019 - Wyn Staheli, Director of Research
Until February 1, 2020, you can preview Find-A-Code's Patient-Driven Groupings Model (PDGM) home health payment calculator by going to https://www.findacode.com/tools/home-health/ .
Hypertension ICD-10-CM Code Reporting Table
November 25th, 2019 - Wyn Staheli, Director of Research
In ICD-10-CM, hypertension code options do not distinguish between malignant and benign or between controlled and uncontrolled. What is important for code selection is knowing if the hypertension is caused by or related to another condition. The following table shows some of these options.
New Medicare Home Health Care Payment Grouper — Are You Ready?
November 25th, 2019 - Wyn Staheli, Director of Research
In 2020, Medicare will begin using a new Patient-Driven Groupings Model (PDGM) for calculating Medicare payment for home health care services. This is probably the biggest change to affect home health care since 2000.
VA: How UCR Charges are Determined
November 20th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
How does the VA determine charges billed to third party payers for Veterans with private health insurance? According to the VA. "38 C.F.R 17.101 stipulates the basic methodology by which VA bills third party insurance carriers. In order to generate a charge for medical services, VA establishes reasonable charges for five ...
Medical Insurance Coverage for TMJ Disorders (TMD)
November 19th, 2019 - Christine Taxin
It is agreed that TMJ disorders should be covered by insurance. There are often questions whether it is covered by medical insurance or dental insurance and where the line is that separates coverage.Medical Insurance typically is the primary insurance for TMJ disorders. The reason is that joints are found anywhere ...
Changes to Portable X-Ray Requirements
November 19th, 2019 - Wyn Staheli, Director of Research
On September 30, 2019, CMS published a final rule which made changes to portable x-ray services requirements as found in the law.
Q/A: Q/A: How do I Code a Procedure for the Primary Insurance so the Secondary Can Get Billed?
November 19th, 2019 - Wyn Staheli, Director of Research
Question: How do you modify a code submitted to the primary insurance company to let them know it is not covered by them so you can bill to a secondary?



About Codapedia by innoviHealth Contact Us Terms of Use Privacy Policy Advertise with Us

innoviHealth - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain) - Fax (801) 770-4428

Copyright © 2000-2019 innoviHealth Systems, Inc. - CPT® copyright 2018 American Medical Association