2025 Gastroenterology Reimbursement and Coding Update (Virtual) | November 2024-11 - Overview of Split-Shared and Incident-To Guidelines

Pdf Summary

The document provides an in-depth overview of billing guidelines and documentation requirements for split-shared and incident-to services, particularly concerning Advanced Practice Providers (APPs). The guidelines are not just limited to Medicare but also affect various commercial payers. <br /><br /><strong>Split-Shared Services:</strong> These involve medical encounters where both a physician and a Non-Physician Practitioner (NPP) perform parts of an Evaluation and Management (E&M) visit. The substantive portion of the visit must be documented to determine which provider's credentials are used for billing. The professional who performs a larger substantive portion of the visit, either through direct patient interaction or decision-making, is generally responsible for billing. Modifier FS is essential for denoting split/shared E&M visits. <br /><br /><strong>Incident-To Services:</strong> These are services offered as part of a patient's normal treatment course, initially performed by a physician and subsequently managed by APPs under physician supervision. For incident-to billing, the physician must be present in the office suite and actively involved in the patient's care. Notably, incident-to services are only billable in outpatient settings, not inpatients or nursing facilities.<br /><br />The document also includes guidelines from various commercial payers like UnitedHealthcare, Anthem BCBS, and Cigna on how services provided by APPs should be billed. Different payers have varying requirements, such as using specific modifiers or ensuring that the APP is registered.<br /><br />Finally, advice is offered for managing billing policies effectively, such as maintaining a spreadsheet of payer requirements, verifying state and payer-specific policies, and ensuring that MDs and APPs belong to the same practice for shared service billing. The presentation emphasizes accuracy in billing practices to ensure compliance and effective reimbursement.

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Concept Split/shared E/M Visit

Concept Incident-to Billing

Concept Substantive Portion

Concept Documentation

Concept Initial Physician Service

Keywords

billing guidelines

documentation requirements

split-shared services

incident-to services

Advanced Practice Providers

Medicare

commercial payers

Evaluation and Management

Modifier FS

billing compliance

Split/shared E/M Visit

Incident-to Billing

Substantive Portion

Documentation

Initial Physician Service