Split Shared Encounters

Split Shared Encounters Explained by Amanda Rumpke, MSN APRN-CNP

Billing & Coding 101 is not a class we took in nursing school. As an APRN starts their practice, each has a bit of a learning curve when it comes to effectively delivering quality documentation that both serves as a complete accounting of the care provided and supports the level billed.  Even for seasoned clinicians, ever-changing and often complicated payer rules make documentation and appropriate billing and coding challenging. Factor in scenarios where the patient is seen and examined by more than one clinician per day and something that is complex in the best of times seems next to impossible to do correctly. 

To that end, this article will explore Centers for Medicare and Medicaid Services (CMS) guidelines that govern the practice of shared-split encounters through a series of common questions and answers. If you still have questions after your review, please see CMS internet-only manual (IOM) Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, Section 30.6.1

First, we will provide you a bit of background. CMS originally defined split-shared services in late 2002 with little change to their guidelines since that time. CMS states that a split / shared encounter is a medically necessary visit where both the Physician and a qualified Non-Physician Practitioner have a face to face encounter on the same encounter date, with each clinician providing substantive documentation that supports one level of service. Sounds straightforward, right? Not so fast, there are other rules and some scenarios that commonly trip practitioners up. 


1. If the APRN examines a hospitalized patient, can a Physician bill for the visit?
The short answer is, sometimes. When both the APRN and the Physician see the patient in the same calendar day AND both provide a substantial contribution to the documentation for a medically necessary visit, then the collective work can be used to support the professional fee for the encounter. Additional rules clarify that the APRN and Physician must be employed by the same group.  


2.  Is it enough for the Physician to simply attest that he or she read and agrees with the APRN note?
No, as noted above, each clinician’s contribution to the level of service must be substantive. The general expectation is for each provider’s portion of the documentation to include some part of the history, physical and medical decision making. While it is not necessary for the Physician to redocument all elements of the service, it is not sufficient to simply “agree with the above”. Let’s walk through an example where the Physician does provide “substantive” documentation: I, as the pulmonary APRN, see a hospitalized patient admitted with a COPD exacerbation. Our service saw the patient three days ago in consultation and I am following up today. He is wheezing and congested when I listen and has oxygen saturations in the high 80s on room air. I document all of the above and order a chest xray as he is more congested than he was. I also order steroids. The Physician I work with comes by and addends my note with the following information: I saw the patient and reviewed the APRNs note. I agree with the above though at the time of my visit the patient was no longer wheezing. I also reviewed the chest xray obtained by the APRN. I am concerned about a pulmonary nodule and will proceed with chest CT. In this example, the Physician’s attestation is not long, only a few sentences really, but does point to her clinical exam and medical decision making which make it a substantive contribution.

3. If the Physician bills, can the APRN also bill?
No. Only one provider from the same specialty can bill for the same service during the same calendar day, unless utilizing a follow-up critical care code.

4. If the APRN bills, does the institution lose money by only collecting 85% of Physician fee?
Unfortunately, many payers – CMS included, reimburse APRNs at 85% of the Physician fee schedule for a given encounter. While on the surface it may seem like “leaving 15% of the fee on the table” is not wise, the cost of ensuring compliance with CMS rules should be considered. In reality, billing incorrectly in order to retain 100% reimbursement can cost much more than what is earned in capturing 100% of the Physician fee schedule. It is also important to note that either provider can bill for a split-shared encounter. Let’s say the patient has a rapid response following your visit for the day and the Physician responds, he may addend your note with his assessment but is not required to bill the encounter under his provider number.

5. Are all types of hospital encounters appropriate for a shared split?
No, not every hospital encounter can be a compliant shared-split visit. CMS permits a split shared approach to history and physical exams, subsequent hospital encounters, discharge summaries and surgical first assist services.  Encounters in a skilled nursing facility, procedures, and critical care time-based encounters are not allowed to be shared. Consultations are less straightforward than the other encounter types. Historically CMS did not allow consultations to be split-shared, however CMS no longer accepts consultations codes. We recommend reviewing your institution’s policy and procedures or posing the question to your compliance team to help guide your practice.

6. Are the rules that govern shared split encounters the same as incident-to?
Shared encounters are only acceptable in an outpatient practice when incident-to rules are met, which may limit the use of shared split billing in the outpatient setting. Remember that incident-to may not be utilized in the hospital setting. Unlike split-shared rules, incident-to does not require a face to face visit by both providers so long as the plan of care was previously established by the Physician and the APRN is merely continuing such care. While a face to face encounter is not required, a Physician must be on site. Such supervision would need to be documented in the course of an audit. Additionally, new patients without previously established plans of care or patients with new problems would be outside the scope of incident-to rules. As with split-shared, not all payers recognize incident-to. All of that factored together, often leads organizations to prohibit incident-to or limit it to certain scenarios.

7. Are the rules that govern shared split encounters the same as resident rules?
No, often split shared rules are confused with those that govern the documentation and appropriate billing for care provided by medical residents supervised by a teaching Physician. This can get especially confusing when an APRN is doing an invasive procedure or providing critical care services. Think about the insertion of a central venous catheter. As long as the APRN is credentialed to provide the service, the procedure can only be billed by the APRN even if the Physician was present. That said, individual institutions may require certain encounter types to have a co-signature if completed by an APRN. As is noted above, a simple co-signature is not considered substantive and is also not relevant if the type of encounter is not one that may be shared under CMS split-shared rules.

8. Are there any good resources to learn more?
While we provided a link to the CMS Manual above, there is often quite a bit of uncertainty. Another great resource is American Academy of Professional Coders website. There you will find multiple resources and some great webinars to help you learn the ins and outs of any type of situation that piques your interest.

Now that you have learned more about some of the complexities of hospital-based documentation and billing, you may develop additional questions. OAAPN is committed to providing valuable resources for your professional practice. If you have questions, do not hesitate to submit them here.


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