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

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This presentation by Kristin Vaughn provides a detailed overview of billing guidelines and documentation requirements related to Split-Shared and Incident-To services, emphasizing that these rules apply beyond Medicare to commercial payers as well.<br /><br />Advanced Practice Providers (APPs)—including Physician Assistants, Nurse Practitioners, Nurse Anesthetists, and others—are licensed providers who can bill independently. Their scope of practice varies by state, institution, and payer.<br /><br />Split-Shared services occur when both a physician and an APP jointly provide a medically necessary Evaluation & Management (E/M) service in the same day. Billing is under the provider who performed the substantive portion, defined by CMS in 2024 as more than half the total time or a substantive part of the medical decision making (MDM). Time must be distinct with overlapping times counted once. Documentation must identify both providers and support the substantive portion performed by the billing provider, with modifier FS used on claims for Medicare.<br /><br />Incident-To services require a physician to have personally initiated treatment and remain actively involved with direct supervision in an office setting. The physician must be physically present in the office suite and review the APP’s notes, signing them. Once the treatment plan changes, billing must switch to the APP. Incident-To billing is not permitted in inpatient or facility settings.<br /><br />Commercial payers such as UnitedHealthcare, Anthem BCBS, and Cigna have varying policies on APP billing. Some reimburse APPs at reduced rates, others require billing under the supervising physician’s NPI if certain criteria aren’t met. Direct billing by APPs is common but payers differ, so providers should verify individual payer policies. Key tips include ensuring proper documentation with unique physician attestations, timely signatures, understanding payer-specific requirements, and maintaining compliance with state scope of practice and supervision laws.<br /><br />Overall, the presentation emphasizes the importance of understanding differences among Medicare and commercial payer policies for compliant and optimized billing of APP services.

Asset Subtitle

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

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Concept Advanced Practice Provider

Concept Split/shared Service

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Concept Incident-to Billing

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Keywords

Split-Shared Services

Incident-To Services

Advanced Practice Providers

Billing Guidelines

Documentation Requirements

Medicare Billing

Commercial Payers

Evaluation and Management (E/M)

Physician Supervision

Payer Policy Compliance

Advanced Practice Provider

Split/shared Service

Substantive Portion

Incident-to Billing

Scope of Practice