Documentation Tips

Documentation Tips: NPPs & Split-Shared Services for Medicare

Documentation Tips: NPPs & Split-Shared Services for Medicare

Medicare defines Non-Physician Practitioners (NPPs) as Physician Assistants (PAs), Nurse Practitioners (NPs), and Clinical Nurse Specialists (CNSs).

Services provided by NPPs can be billed to Medicare in one of three ways:

  • Using the NPPs own provider number. This generates 85% of the Medicare Physician Fee Schedule (MPFS) amount.
  • “Incident-to” a physician service. This generates 100% of the MPFS but it is not applicable in ED setting.
  • Split/Shared service with the physician. This generates 100% of the MPFS.

When an ED E/M visit is split or shared between a physician and NPP from the same group practice, the E/M visit may be billed under the physician’s provider number if the physician provides and documents in the ED record any meaningful face-to-face portion of the E/M service.  A co-signature alone or generic “I agree with NP notes” does not signify this.

If the physician does not personally perform and document a face-to-face portion of the E/M service with the patient, then the encounter is not billed under the physician’s provider number and is billed only under the NPP’s provider number.  Some examples of unacceptable split/shared visit documentation would be: “Agree with above” with co-signature; “Discussed with NPP. Agree”; “Patient seen and evaluated”; “Seen and agree”, etc.

The medical record must clearly identify both the NPP and the emergency physician who shared in rendering the service.  The physician documentation should be linked to the NPP documentation of the shared service and should affirmatively state one or more elements of the history, physical examination, or medical decision-making.

A critical care code cannot be reported as a split/shared E/M service. Each critical care service must reflect the evaluation, treatment and management by the individual physician or qualified non-physician practitioner and may not be represented by a combined service between a physician and a qualified NPP. Times for each provider must be reported separately.

Procedures and diagnostic interpretive services performed by the NPP must be billed using the NPP’s number alone.  The shared service rules only apply to E/M services.

It is important to note that this policy specifically describes Medicare regulations but private payers may follow very different policies for their billing requirements.  Many private payers do not issue numbers to NPPs and request that billing occur under a supervising physician. Some payers may only ask to follow state law when NPPs deliver care.  For such cases, it may be appropriate for the NPP to provide care without a physician face-to-face encounter in the ED and bill the private payer under the physician’s number.

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