Incident To and Split/Shared Services Frequently Asked Questions

Question: Does the supervising provider have to be in the same location/office? We have three facilities in three different locations. Can a provider in one location supervise someone in another location?

Answer: The supervising provider does not have to be physically present in the patient's treatment room while the services are provided, but he/she must provide direct supervision. They must be present in the office suite to render assistance if necessary.

Question: Can incident to occur in place of service (POS) 19 or 22 (outpatient hospital)?

Answer: No. Incident to services are limited to the office setting (POS 11). However, if a provider establishes an office in a larger outpatient setting, the incident to services and requirements are confined to this discrete part of the facility designated as his/her office.

• Hospital Based Physician (employees of the hospital)
  • The hospital is billing and incident to does not apply
  • Bill POS 19 or 22
• Group of physicians (not employees of the hospital) and the office is confined to the discrete part of the facility
  • The physicians are incurring the expense then incident to would apply
  • Bill POS 11 (not POS 19 or 22)

Question: Can a nonphysician practitioner (NPP) supervise another NPP?

Answer: No. An NPP may supervise auxiliary personnel (nurses, medical assistants etc.).

Question: If the physician is on the second floor, but the NPP is performing a service on the first floor can we bill incident to?

Answer: No. The supervising provider must be present in the office or office suite to render assistance if necessary to meet the incident to requirements.

Question: Who is required to sign the medical record if the service is split/shared or incident to?

Answer: The chart below contains the signature guidelines for incident to and split/shared services.

Situation	Performed By	Signature Requirement
Incident to	Ancillary Staff	Must be signed by supervising provider (billing)
	NPP	May be signed by the NPP or the supervising physician
Split/Shared: Office/Clinic Setting	NPP and Physician	May be signed by the NPP or the supervising physician. If this service is billed under the physician’s NPI, the billing physician must sign the record. Additionally, the documentation must include a statement that the billing provider had face-to-face contact with the patient and performed a substantive portion of the E/M visit. (A substantive portion of the E/M visit includes at least one of the three key components (history, exam, or medical decision making.)
Split/Shared: Hospital Inpatient/ Outpatient/Emergency Department Setting	NPP and Physician	Must be signed by billing provider. If this service is billed under the physician’s NPI, the billing physician must sign the record. Additionally, the documentation must include a statement that the billing provider had face-to-face contact with the patient and performed a substantive portion of the E/M visit. (A substantive portion of the E/M visit includes at least one of the three key components (history, exam, or medical decision making.)

Question: Can a split/shared service occur in POS 19 or 22 (outpatient hospital)?

Answer: When a hospital inpatient/hospital outpatient or emergency department Evaluation and Management (E/M) is 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, the service may be billed under either the physician's or the NPP's National Provider Identifier (NPI). However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPP's NPI.

Note: The physician must document a substantive portion of the E/M service. A substantive portion of an E/M visit involves at least one of the three key components (history, examination, or medical decision making).

Question: Can any physician bill incident to within the group (different specialty)? Example, the patient established care with an Orthopedic surgeon, but was supervised by the Pain Management physician.

Answer: The supervising provider must be a member of the group (any specialty).

Question: Where can you find the signature requirement information?

Answer: The signature guidelines are located in the Medicare Program Integrity Manual, 100-08, Chapter 3, Section 3.3.2.4. In addition to the manual, Palmetto GBA has published an article Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices

Question: Does incident to apply to the emergency department?

Answer: Incident to does not apply to the emergency department services.

Question: Can a resident and a teaching physician render a split/shared service?

Answer: No. A split/shared service occurs between an NPP and a physician. Please refer to the Teaching Physician Services guidelines (PDF, 1.9 MB) in the Medicare Claims Processing Manual.

Question: Can a PA bill for an inpatient hospital visit?

Answer: If a physician assistant (PA) sees a patient in the hospital and the physician does not have a face-to-face encounter and/or a substantive portion of the E/M service is not document, then the service may only be billed under the PA's NPI.

Question: We have a PA that is new to our practice. She sees the patients and we bill Medicare under her NPI. There is a supervising physician on site but they do not comment on the documentation nor do they share face-to-face encounters. Should we bill a special way?

Answer: If the incident to requirements is met the service may be billed under the physician’s NPI. If the incident to requirements is not met the service would be billed under the PA’s NPI.

Question: Can a PA or NP bill Medicare for their services and what is the difference in payment?

Answer: If the physician assistant (PA) or nurse practitioner (NP) has enrolled in Medicare and it is within their scope of practice, he/she may bill Medicare for their service. Payment will be made at 85 percent of the Medicare Physician fee schedule.

Question: Can you bill split/shared services for skilled nursing facility (SNF) and nursing facility (NF)?

Answer: No. Split/shared services cannot be performed for nursing facility services, critical care services or procedures.

Question: What happens when a service, example chemotherapy is started when the physician and NPP is in the office, but then the physician leaves mid treatment? Which NPI should we use?

Answer: Since the physician left the office mid treatment (the supervision requirements were not met for direct supervision) the service would be submitted under the NPP’s NPI since he/she was there during the entire treatment.

Question: Can a critical care service be performed split/shared (any setting)?

Answer: No. Split/shared services cannot be performed for nursing facility services, critical care services or procedures.

Question: If a nurse provides/documents an injection, and the physician signs the nurse's documentation, but the nurse does not sign it, is this is acceptable to Palmetto GBA?

Answer: The physician’s must sign the documentation (exception pneumococcal, influenza, and hepatitis B vaccines). Anyone who documents in the medical record should sign their entry.

Question: If a nurse practitioner sees a patient in a SNF or NF, but not in a separate office, can this be billed as incident to? The patients are being seen in their room at the facility.

Answer: No. In institutions including NF/SNF, your office must be confined to a separately identifiable part of the facility and cannot be construed to extend throughout the entire facility.

Question: Can we bill incident to if a NPP performs a new procedure for a new problem/condition?

Answer: There must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment. This service must be submitted under the NPP’s NPI number. A service cannot be submitted incident to even when the NPP only orders diagnostic or laboratory tests, unless the physician provides a face-to-face encounter and establishes the course of treatment (e.g., need for X-ray, apply ice, etc.).

Question: The split/shared guidelines state the physician must document a substantive portion of the E/M service (Inpatient/Hospital Outpatient/Emergency Department), what does substantive mean?

Answer: A substantive portion of an E/M visit involves at least one of the three key components (history, examination, or medical decision making). A co-signature alone or a statement such as "Agree with the above" is not acceptable.

Question: Is there a set amount of time between office visits to be considered a new problem?

Answer: No. The documentation must support if the problem/condition is new, chronic etc.

Question: When a NPP performs a procedure in an inpatient setting, does the physician need to sign the report, or should there just be a reference to the fact that the service was supervised by Dr. X with the NPP signing the report?

Answer: Incident to does not apply to the inpatient setting. The documentation must be signed by the NPP and submitted under the NPP’s NPI.

Question: If a service is performed split/shared in the Inpatient/Hospital Outpatient/Emergency Department setting will the physician signature support that a face-to-face occurred.

Answer: No. The physician must document a substantive portion of the E/M service. A substantive portion of an E/M visit involves at least one of the three key components (History, Examination, or Medical Decision Making). A co-signature alone or a statement such as "Agree with the above" is not acceptable.

Question: If a patient is treated for an upper respiratory infection and then returns two months later with the same diagnosis is this considered a new problem?

Answer: It would be considered a new problem. If the patient has a chronic condition or exacerbation of a chronic condition it would be considered an established problem (the documentation must be concise).

Question: What are the supervision requirements for diagnostic tests?

Answer: CMS Change Request (CR) 7554 (PDF, 325 KB) identifies the physician supervision requirements for diagnostic procedures (refer to Section 31A on pages 16 and 17). Each diagnostic test has an assigned, required level of supervision in the CMS Medicare Physician Fee Schedule Database (MPFSDB). We recommend you access the MPFSDB for each specific diagnostic test to find the level of supervision under Medicare.

Question: Can incident to billing occur with practices using Provider Based Billing status?

Answer: Assuming the provider is billing with POS 22 (outpatient hospital), if a provider establishes an office in a larger outpatient setting, the incident to services and requirements are confined to this discrete part of the facility designated as his/her office.

Question: Will the lower NPP allowance apply to drugs and administration codes or just E/M services?

Answer: When a NPP bills for a service under their NPI number, services are paid at 85 percent of the amount that a physician is paid under the Medicare Physician Fee Schedule (PFS). Other payment rules will still apply (drugs, laboratory etc. are paid at the normal rate).

Resources:

• Internet Only Manual
  • Incident To: Pub. 100-02, Chapter 15, § 60.1. B, 60.2
  • Split/Shared E/M Services: Pub. 100-04, Chapter 12, § 30.6.1 B and 30.6.13H