2026 Gastroenterology Reimbursement and Coding Update (On-Demand) | November 2025-Overview of Split-Shared/Incident-to Guidelines and Documentation Requirements: Not Just for Medicare!!!

Overview of Split-Shared/Incident-to Guidelines and Documentation Requirements: Not Just for Medicare!!!

Video Transcription

Video Summary

This presentation covers split/shared visits and incident-to billing guidelines, focusing on Advanced Practice Providers (APPs) such as nurse practitioners and physician assistants. APPs have their own NPIs and typically receive 85% of the physician fee schedule, while physicians get 100%. For split/shared visits (hospital settings), the provider who performs the substantive portion of the visit bills, identified by modifier FS. Time spent or decision-making complexity determines who performed the substantive portion, with thorough documentation required. Incident-to services apply only in office settings (POS 11), where the physician initially establishes the treatment plan and the APP follows it without changes; these can be billed under the physician’s NPI at full fee. If treatment changes, billing must shift to the APP’s NPI. Commercial payers vary: UnitedHealthcare reimburses APP services at 85%, Anthem requires services by recognized NPIs to be billed directly under those NPIs rather than incident to, and Cigna registers but does not credential APPs, expecting claims under the APP's NPI. Proper documentation protocols and supervision requirements are critical to compliance and reimbursement.

Asset Subtitle

Kristin Vaughn, CPC, QMC, QMGC, CPMA, ICDCT-CM

Keywords

split/shared visits

incident-to billing

Advanced Practice Providers

modifier FS

physician fee schedule

commercial payer policies