Split/Shared and Incident-To Documentation and Billing Compliance

Split/Shared and incident-to billing have been highlighted as high-risk compliance and revenue risk areas. There have been numerous government audit reports and False Claims Act settlements related to improper billing of split/shared and incident-to services dating back many years. The government’s focus on this area is due to the 15% reimbursement increase when services are billed using a physician’s provider number. Services billed using a non-physician practitioner such as a physician assistant or nurse practitioner are reimbursed at 85% of the physician fee schedule rate. To further complicate matters, these Medicare billing rules may or may not be recognized by other payers. In fact, many insurers prohibit billing of NPP services using a physician provider number. Additionally, obtaining physician buy-in and cooperation has been challenging since in most instances, they are ultimately responsible for the supervision of the NPP and the patient and believe they should be compensated accordingly. Lastly, functionality of various electronic health record systems has impeded the ability of providers and organizations to accurately document, track and bill split/shared and incident-to services in accordance with CMS requirements.

As mentioned, providers have struggled to compliantly bill for incident-to and split/shared services for years. However, compliance with the split/shared services rules have become one of the biggest provider challenges since CMS finalized changes to the regulations effective January 1, 2022, with additional changes expected from both the AMA and CMS for 2024. The current regulations apply to E/M services rendered jointly in a facility by a physician and a NPP. The CMS regulations which require split/shared services to be billed by the provider who performed the “substantive portion” of the encounter along with modifier FS to indicate the billed service(s) were rendered as split/shared have created significant operational challenges for providers as well as revenue concerns. These concerns stem from the expectation that a significant number of encounters will no longer meet the criteria to be billed using a physician’s provider number resulting in a 15% payment decrease for each of these encounters potentially resulting in significant revenue losses annually. The expected revenue impact is forcing organizations to take a critical look at their clinical workflows, use of NPPs, and physician compensation models.

Many organizations have sounded the alarm that compliance with the new requirements has been not only difficult to achieve but nearly impossible to effectively audit and monitor. This session will review the documentation and billing requirements for split/shared and incident-to services. We will address common errors related to both. We will explore proven methods for conducting effective auditing and monitoring of split/shared and incident-to services. Finally, we will provide recommendations to improve compliance and reduce financial risk.

Learning Outcomes:

• Understand core differences between incident-to and split/shared
• Identify the documentation and billing requirements for incident-to
• Identify the documentation and billing requirements for split/shared
• Explore auditing and monitoring methods
• Provide recommendations for organizational success

Areas Covered in the Session:

• Incident-To Billing Rules
• Criteria to bill Incident-to
  • Services must be rendered in a physician office (POS 11)
  • Service must be rendered under direct supervision (supervising must be in the office)
  • There Must be an employment relationship between the APP and the MD
  • Services must be for an established patient
  • Services must be for an established condition (diagnosis)
  • Services must be rendered as part of an established treatment plan developed by the physician
• Not bill an APP service using the incident-to
  • New patients
  • New conditions
  • New treatment plans
  • Services rendered without direct MD supervision (physician out of office when service rendered)
  • Services rendered in a facility (i.e., hospital)
  • Services rendered by a non-employee
• Process for identifying the billing provider when an APP renders a service
  • What if the physician is late to the clinic?
  • What if the physician leaves early?
  • What if the physician gets called away for an emergency?
  • What if the patient has a new complaint?
  • What if the APP changes the treatment plan?
• Split/Shared Services Billing Rules
• Split/Shared
  • Facility (Excludes POS 11) only
  • New or established patients
  • New or established problems
  • New or established treatment plans
  • Rendered by APP and physician
  • Medicare specific requirements that not all payers may follow
• Documentation for Split/Shared services
• Auditing and monitoring
• Summary

Recommended participants:

• Compliance professionals
• Clinical staff, including physicians, APPs and ancillary staff
• Health information management professionals
• Clinical documentation improvement professionals
• Quality improvement professionals
• Providers
• Coders
• Clinic managers
• Denial management staff
• Accounts payable staff
• Auditors
• Office Managers
• Denial resolution teams
• Insurance payers
• Payment policymakers
• Billing Staff
• Coding Staff
• Physician and Non-physician Practitioners
• Insurance Company Claims Reviewers

Presenter Biography: