A physician and a nonphysician practitioner (NPP) team up to provide an E/M service. So which is it—an incident-to service or a split/shared visit?

If you want to get paid appropriately—and without raising red flags among payers—you need to clear up the confusion once and for all.

Knowledge is Money

Both incident-to and split-visit coding are profitable for medical practices, as they allow their nonphysician practitioner (NPP) to serve as physician extenders. If a NPP teams with a physician for either service, the practice may code the visit under the physician’s National Provider Identifier (NPI). This qualifies the NPP services to receive the total allowed payout—compared to NPP services performed independent of the supervising physician, which must be filed under the NPP’s NPI and will only receive 85 percent of the allowed payout.

The Hallmarks of Distinction

Let’s look at the three main factors that distinguish split visits from incident-to billing.

1. Place of Service (POS). The first difference is that split/shared visits pertain to inpatient encounters, as well as E/M visits that occur in hospital outpatient departments or provider-based clinics. It is not a split/shared visit if it occurs in the medical practice’s office (POS 11).
2. Provider Duo. The second difference is that split/shared visits pertain to two qualified providers actively involved in the visit. Both physician and NPP see the patient and provide a portion of the service.

If a NPP performs a service independent of the supervising physician, you can code the service incident-to, providing that the criteria are met:

• The supervising physician is in the office.
• The patient is established.
• The supervising physician has previously seen the patient for the condition and has established a plan of care.

3. Date of Service. A third difference is that split/shared visits always involve two providers who see the patient on the same date.

Incident-to services refer to the NPP serving as a physician extender. In other words, the NPP is seeing a patient on the physician’s behalf, not simultaneously working alongside the physician.

For split/shared coding, you must prove that two providers teamed up to provide a complete E/M on the same date. Practices frequently lack either the supervising physician or NPP’s medical notes, and therefore fail to demonstrate that both providers participated in the visit. Detailed documentation is a must to avoid claim denial and loss of payment.

Not All Payers are Alike

Incident-to and split visit coding are Medicare developments. While payers typically follow Medicare, not all have adopted incident-to and split-visit rules. Always check with your insurance carriers to learn their stance on incident-to and split-visit billing.

Author Bio: Deborah Marsh, JD, MA, CPC, CHONC, is a senior content specialist for TCI SuperCoder, working on everything from online tool enhancements and data updates to social media and blog posts. Deborah joined TCI in 2004 as a member of TCI’s respected Coding Alert editorial team.