Split/Shared Visits in Inpatient Hospital or Emergency Department

Current reviews of medical records indicate an increasing number of Inpatient Hospital and Emergency Department services being submitted as split/shared visits between a physician and Non-Physician Practitioner (NPP) from the same group practice. The purpose of this article is to provide guidance on the appropriate documentation of split/shared services.

For a split/shared service to be reimbursed by Medicare Part B, the supporting medical records must satisfy certain documentation requirements (found in the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 30.6.1B. These requirements specify, in part:

Split/shared visits may be submitted with physician's PTAN as long as the following conditions are met:

  • The NPP and physician are employed by the same employer or are in the same group practice
  • The physician MUST have a medically necessary encounter where the physician and the NPP each personally perform a substantive portion of an E/M visit (face to face encounter) with the patient on the same day
    • “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"
    • This encounter must consist of more than a review of the medical record by the physician”

Sufficient medical record documentation is the key to proper reimbursement. In all cases, documentation must substantiate the medical necessity of the shared/split visit; support the level of E/M code submitted, and the medical record should contain enough detail to allow a reviewer to:

  • Identify both providers
  • Link the physician notes to those of the NPP
  • Include legible signatures from both providers
  • Confirm that the physician and the NPP both saw the patient face-to-face
  • Include legible/electronic signature

Following are examples of physician documentation that would meet these criteria:

“I have personally performed a face to face diagnostic evaluation on this patient. My findings are as follows: …Patient presents with abscess, onset 3 days ago. Has tried a warm compress; hot shower for relief. Exam shows right gluteal abscess 3cm warm tender and fluctuant. Incision and drainage not indicated, started on MRSA antibiotic coverage" Signed by treating physician

“I have personally performed a face to face diagnostic evaluation on this patient. I have reviewed and agree with the care plan. History and Exam by me shows: abdomen was tender to touch, no rebound. Labs /CT scan negative. IM Toradol given for pain. Pt discharged home.”  Signed by treating physician

Other important notes:

  • When documentation supports that the physician performed a face-to-face portion of the E/M encounter along with the NPP, the E/M service may be submitted under either the physician’s or the NPP’s PTAN. For example: the NPP sees the patient in the hospital or emergency room setting and the physician follows with a documented face-to-face visit with the patient on the same day that supports participation in exam or decision making.
  • If the documentation does not support the physician performed any part of the face-to-face components of an evaluation and management encounter, then the service must only be submitted under the NPP’s NPI. For example, the documentation supports the physician participated only in the reviewing of the patient’s record.

The following are a few 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 History, 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

Resources: 
Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 30.6.1B (PDF, 1.13 MB)

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