By: Claudia Murray, RCC, RCCIR, FRBMA; Senior Vice President, Regulatory Affairs and Corporate Compliance Officer and Mary L. Horkey, RCCIR, RCC, MSN-ARC; MSN Senior Coding Manager
The physician and nonphysician provider (NPP, for example Physician Assistant or Nurse Practitioner) together provide services to a patient. Who bills? It depends—and your decision may have a MIPS impact.
While there are variations in billing requirements, the first determination involves whether the procedure was performed in a physician-directed clinic or as an evaluation and management (E/M) service at a hospital or skilled nursing facility.
- If provided in a hospital setting, either in- or outpatient, the services are classified as “split or shared services” and billable by either the physician or the NPP. In this instance, the person who performs a substantive portion of the service bills for it. The physician is paid at a higher level than the NPP.
- If provided on an outpatient basis at a freestanding physician-directed clinic/office, the service is classified as “incident to” and normally billed under the physician’s National Provider Identifier Standard (NPI), although it is possible for the NPP to bill under specific circumstances. Payment is made to the physician based on 100% of the allowed physician fee schedule amount.
Hospital (Facility) Settings May Qualify for Split/Shared Visits
Because the services appear so similar by definition, the 2024 Medicare Physician Fee Schedule (MPFS) provides valuable direction regarding how to determine who provided the “substantive portion” of the split or shared service as follows:
Split (or shared) E/M visits refer to visits provided in part by physicians and in part by other nonphysician practitioners in hospitals and other institutional settings. For CY 2024, we are finalizing a revision to our definition of “substantive portion” of a split (or shared) visit to include the revisions to the Current Procedural Terminology (CPT) guidelines, such that for Medicare billing purposes, the “substantive portion” means more than half of the total time spent by the physician or nonphysician practitioner performing the split (or shared) visit, OR a substantive part of the medical decision making. This responds to public comments asking that we allow either time or medical decision making to serve as the substantive portion of a split (or shared) visit.[1]
Therefore, if the physician uses the services of his/her own employees in a hospital setting and the physician merely supervises those services, the physician is not eligible for a payment from Medicare.
Although the physician’s employees might meet the supervision and employment requirements generally applicable to “incident to” services in other settings, this is not the case for the hospital setting. “Incident to” is not allowed in the hospital setting and supervision alone does not constitute a reimbursable practitioner service. However, shared visits are allowed as long as the physician personally performs the practitioner service. If the physician does not personally perform at least a substantive portion of the service, or more than half of the total encounter time, the physician is not entitled to any practitioner payment.
Medical record documentation
Documentation in the medical record must identify the physician and NPP who performed the visit, including tasks performed by each individual in the encounter. The individual performing the substantive portion of the visit (and who therefore bills for the visit) must sign and date the medical record.
NPP “Incident To” Requirements for Billing in a Clinic Setting
All the following requirements must be met before a Non Physician Practitioner (NPP) may bill under the “incident to” provision:
- The NPP must be an employee of the physician and
- The initial visit (for that condition) must be performed by the physician. This does not mean that on each occasion of an incidental service performed by an NPP, the patient must also see the physician. It does mean there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the services being performed by the NPP is an incidental part. Some carriers may require periodic encounters with the physician and local requirements should be verified for this issue.
- There must be direct personal supervision by the physician as an integral part of the physician’s personal in-office service. The physician must be physically present in the same office suite and be immediately available to render assistance if necessary OR providing direct supervision through real-time audio and visual interactive telecommunication technology for “incident to” services or other outpatient visits for evaluation and management of an established patient who may not require the presence of a physician or other qualified healthcare professional. (Note: for all other services furnished under the direct supervision of a physician or other practitioner, CMS has proposed continuing to define “immediate availability” through real-time audio and visual interactive telecommunications technology only through December 31, 2025.)
- The physician has an active part in the ongoing care of the patient. Subsequent services by the physician must be of a frequency that reflects his/her continuing active participation in, and management of, the course of the treatment.
Physician-Directed Clinics
A physician-directed clinic meets the following requirements:
- A physician (or a number of physicians) is present to perform medical (rather than administrative) services at all times the clinic is open;
- Each patient is under the care of a clinic physician; and,
- The non-physician services are under medical supervision.
In highly organized clinics, particularly those which are departmentalized, direct personal physician supervision may be the responsibility of several physicians as opposed to an individual attending physician. In this situation, medical management of all services provided in the clinic is assured. The physician ordering a particular service need not be the physician who is supervising the service.
To satisfy the employment requirement, the non-physician (either leased or directly employed) must be considered an employee of the supervising physician or other entity under the common law test of an employer/employee relationship.
Claudia Murray
RCC, RCCIR, FRBMA
Senior Vice President, Regulatory Affairs and Corporate Compliance Officer
Claudia brings an extensive background in Medicare regulations, law and billing processes having spent more than 20 years with the Medicare program in various roles. Prior to joining MSN Healthcare Solutions as their full-time compliance officer, Claudia headed a small consulting firm specializing in radiology and other hospital-based specialties. She consulted with MSN for 15 years in designing, implementing and advising on their compliance programs. Currently at MSN, Claudia is responsible for the myriad activities for HIPAA and corporate compliance as well as the Quality Payment Programs, bringing her full circle to CMS regulations and programs.
Mary Horkey
RCCIR, RCC, MSN-ARC
MSN Senior Coding Manager
Mary Horkey is a Radiology Certified Coder in Interventional Radiology (RCCIR) and a Radiology Certified Coder (RCC). She is a Senior Coding Manager with MSN Healthcare Solutions, with a special emphasis in education and training.
