What are the Medicare requirements for shared services?

Answer: Documenting shared services correctly depends on the place of service.

For the Office/Clinic Setting

  • When an evaluation and management (E/M) service is a shared/split encounter between a physician and a nonphysician practitioner (NPP), the service is considered to have been performed "incident to" if the requirements for "incident to" services are met and the patient is an established patient
  • If incident to requirements are not met for the shared/split E/M service, the service must be submitted under the NPP’s National Provider Identifier (NPI) and payment will be made at the appropriate physician fee schedule payment

For the Hospital Inpatient/Outpatient/Emergency Department Setting

  • When an E/M service is a shared/split encounter between a physician and a NPP from the same group practice, and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be submitted under either the physician’s or the NPP’s NPI number
  • If there was no face-to-face encounter between the patient and the physician (even if the physician participated in the service by only reviewing the patient’s medical record) then the service must only be submitted under the NPP’s NPI
  • Payment will be made at the appropriate physician fee schedule rate based on the NPI entered on the claim
  • For example, if the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service

The documentation collectively would have to support the CPT code that is submitted. For a review, you would have to provide both the documentation from the nurse and the physician for that shared visit so that it supports the CPT code that you submitted.

Resource: Medicare Claims Processing Manual (Pub. 100-04), Chapter 12, Section 30.6.1B (PDF, 1.05 MB).

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