Understanding Incident To and Split Service Billing Across Office, Hospital, and Nursing Home Locations
In the complex world of medical billing, understanding the appropriate use of “incident to” and split/shared service billing is crucial for ensuring compliance and maximizing reimbursement. These billing practices are essential for various healthcare settings, including office, hospital, and nursing home locations. This blog post will provide a detailed overview of when and how to appropriately use these billing methods.
Incident To Billing
“Incident to” billing is a Medicare provision that allows services provided by non-physician practitioners (NPPs) to be billed under a supervising physician’s National Provider Identifier (NPI) at 100% of the physician fee schedule rate. This billing method is primarily used in an office setting but has specific requirements and limitations.
Office Setting:
Supervision: The physician must provide either Direct or remote supervision to NPP.
Initiation by Physician: The service must be an integral part of the patient’s normal course of treatment, initiated by the physician.
Ongoing Involvement: The physician must actively participate in and manage the course of treatment, with the NPP providing follow-up care.
Employment: The NPP must be an employee, leased employee, or independent contractor of the physician or the physician’s practice.
When Appropriate:
- Follow-up visits for established patients where the physician has already established a diagnosis and treatment plan.
- Routine services such as blood pressure checks, injections, or wound care are provided under the direct supervision of the physician.
Be Aware:
- If the patient present with new or worsening problem, the Visit requires direct participation of the MD or should be billed the under NPP.
- NNP documentation should reference a supervising physician was present in the office or that direct supervision was provided & that they are providing follow-up care to the physician’s established plan of care.
- Example: “I am providing follow-up care for this patient’s conditions under the direct supervision of Dr. jones who established the initial plan of care on [date]. Dr. Jones was present & available in the office suit during the visit.
- Physician Must demonstrate periodic review & oversight (this may be achieved by Participating In and/or reviewing follow-up visit.
- Certain Insurances such as BCBS asked to user Modifier SA to get paid for all non-surgical services which performed by NP or PA. BCBS shall be reimbursed these services at 85% of the Applicable Horizon BCBS fee Schedule.
Split/Shared Service Billing
Split/shared service billing allows for a service provided in a facility setting (inpatient, outpatient, emergency department, SNF or Critical Care) to be billed under either the physician or the NPP, provided both have performed a substantive portion of the service face-to-face with the patient.
What is Substantive Portion of the Service?
Substantive Portion can be categorized into two sections:
- Provider who Performed Risk factor Category of the MDM.
- The Provider who performed 2 out of 3 MDM Elements.
Note:
As per CMS claim processing Manual Chapter 12 we suppose to know below rules before performing Spit/Shared Services.
- Office visits and Nursing facility visits aren’t billable as split or shared services.
- Modifier FS should be Reported with Appropriate E/M code.
Provider can review above referance manual here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
Hospital Setting (Inpatient/Outpatient/ED/Critical Care):
Shared Visit: One of the practitioners must have a face-to-face (in-person) contact with the patient, but it does not necessarily have to be the physician nor the practitioner who performs the substantive portion and bills for the visit.
Documentation: Documentation must clearly indicate the participation of both the physician and the NPP, detailing their individual contributions.
When Appropriate:
- Initial or subsequent hospital visits where both the physician and NPP contribute to the patient’s care.
- Complex cases requiring collaborative input from both a physician and an NPP.
Skilled Nursing Setting:
Shared Visit: Like the hospital setting, one of the practitioners must have a face-to-face (in-person) contact with the patient, but it does not necessarily have to be the physician nor the practitioner who performs the substantive portion and bills for the visit.
Direct Patient Care: The same principles of shared responsibility and documentation apply, ensuring both providers contribute meaningfully to the patient’s care.
When Appropriate:
- Comprehensive Skilled Nursing assessments involving both the physician and NPP.
- Follow-up visits for residents requiring detailed evaluations from both providers
Conclusion:
Understanding when to use “incident to” and split/shared service billing is essential for proper reimbursement and compliance with Medicare guidelines. In office settings, “incident to” billing can be utilized for follow-up care and routine services under direct physician supervision. In hospital and nursing home settings, split/shared service billing is appropriate when both the physician and NPP perform substantive portions of the patient’s care.
By adhering to these guidelines, healthcare providers can ensure they are maximizing their billing efficiency while maintaining compliance with regulatory requirements. Accurate documentation and a clear understanding of each billing method’s requirements are key to successful implementation in various healthcare settings.