Shared/split services in the hospital remain a source of questions about proper documentation, coding, and billing. Shared/split services are those where a physician and a non-physician practitioner (NPP) each perform a substantive portion of an evaluation/management (E/M) visit, face to face with the same patient on the same date of service. NPPs include physician assistants (PAs), nurse practitioners (NPs), and clinical nurse specialists.
To constitute a substantive portion of an E/M visit, all or some portion of the key components of an E/M service should be provided: history, physical exam, and/or medical decision making. The level of service for the E/M visit is determined by the combination of the key components documented by both the physician and the NPP, as if the service and documentation had been performed by a single clinician.
The physician and the NPP must be members of the same group practice or be employed by the same employer. Claims for shared/split services may be filed under either the physician's or the NPP's National Provider Identifier (NPI). The claim is typically filed using the physician's NPI, allowing the practice to take advantage of the higher reimbursement rate for the physician since Medicare pays NPPs only 85% of the Physician Fee Schedule.
Split/shared services apply to specific E/M services. For the inpatient setting, these include:
- Initial hospital care (99221-99223)
- Subsequent hospital care (99231-99233)
- Observation care (99217-99220, 99224-99226, 99234-99236)
- Prolonged services (99356-99357)
Split/shared services do not apply to critical care services (99291, 99292) which reflect critical care provided for a specified reportable period of time by an individual clinician, whether a physician or NPP, using that clinician's NPI.
For a split/shared visit, both the physician and the NPP must provide face-to-face services personally and each of them must document their parts of the visit. The physician's documentation must clearly indicate that a face-to-face visit occurred; a statement to this effect or inclusion of some components of a history and physical exam could meet this requirement.
It is not sufficient for the physician to review the medical record and/or the NPP's note and simply agree with and sign off on the NPP's note. The physician must see the patient face to face and specifically document his or her findings or split/shared services cannot be billed and the claim must be filed using the NPP's NPI.
An example of physician documentation that would not qualify for split/shared services is a statement signed by the physician saying, “I have personally seen and examined the patient independently; reviewed the PA's history, physical exam, and assessment/plan; and agree.” Even though the physician documented a face-to-face encounter, she did not document any of the components of an E/M service that would be required for split/shared billing.
A familiar scenario not qualifying for split/shared services would be a patient admitted and evaluated by an NPP. The NPP documents the history, physical exam, and medical decision making and gives the physician an update on the patient's status. Later, the physician makes rounds and concurs with the NPP's note and plan of care.
What sort of documentation would justify a split/shared services claim? Suppose a PA admits a patient and documents the following:
- A comprehensive history with 6 elements; a complete review of 12 organ systems; and a past, family, and social history
- 9 components of a comprehensive physical exam
- Medical decision making of moderate complexity with 2 diagnoses, moderate severity of illness, and moderate complexity of data reviewed
The physician sees the patient shortly thereafter and documents that he saw and examined the patient with the following findings:
- 3 elements of a brief history but no review of systems or past, family, and social history
- A limited examination of 2 body areas
- Medical decision making of high complexity with 5 diagnoses requiring management, moderate severity of illness, and extensive complexity of data reviewed
Taken alone, the PA's documentation amounts to a level 2 initial inpatient visit (99222) billed at 85% of the Physician Fee Schedule. The physician's documentation alone is insufficient to qualify for billing as an initial inpatient visit at any level. However, combined as a split/shared service, the documentation qualifies for a level 3 initial inpatient visit (99223), based on a comprehensive history and physical exam by the PA and a high complexity of medical decision making by the physician. Code 99223 can be submitted using the physician's NPI for reimbursement at 100% of the Physician Fee Schedule.
Commercial payers and state Medicaid programs may have different requirements for payment of NPP services and split/shared services. A prudent approach would be to contact these payers to determine exactly how these circumstances are to be handled.
Clinicians sometimes confuse split/shared services with “incident-to” services. Incident-to services are those provided by any health care personnel without a face-to-face encounter by a clinician (physician or NPP). They are part of the patient's normal course of treatment, and the billing clinician must have personally performed an initial service and remain actively involved in the course of treatment. Incident-to services are billed using the clinician's NPI and are paid at 100% of the Physician Fee Schedule for physicians and 85% for supervising NPPs. Incident-to services cannot be billed for inpatient care and are therefore not pertinent to hospitalists.
In summary, if both the physician and the NPP see, evaluate, and document face-to-face encounters with a patient, a claim may be filed for the level of service supported by their combined documentation using the physician's NPI for reimbursement at 100% of the Medicare Physician Fee Schedule. Commercial payers and state Medicaid programs may have different rules.