In radiology, the most common physician employed Non-Physician Practitioners (NPP) are Physician Assistants (PA) and Nurse Practitioners (NP). When NPPs are used in a hospital place of service (POS) the services they provide under Part B have to be billed using the national provider identifier (NPI) of the NPP as “incident to” billing is not allowed. There is a possible exception ─ when the service in question is for evaluation and management (E/M).

Incident to

According to the Centers for Medicare & Medicaid (CMS) “Incident to services are defined as those services that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home. These services are billed as Part B services to your carrier as if you personally provided them, and are paid under the physician fee schedule.”1 (Emphasis added.)

It is the understanding that we cannot bill using “incident to” in a hospital POS that is important as we shift consideration to shared/split E/M service. In a hospital POS NPPs bill using their own NPI and they receive 85% of the Medicare Physician Fee Schedule (MPFS) for that service. A shared/split E/M service allows the work of the NPP and the physician to be joined and billed under the physician’s NPI thereby receiving 100% of the MPFS, as long as we follow the rules of course.

Share/split E/M service

CMS defines a shared/split E/M service as “When a hospital inpatient/hospital outpatient (on campus-outpatient hospital or off campus outpatient hospital) or emergency department E/M is shared between a physician and an 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 billed under either the physician's or the NPP's UPIN/PIN number.”2

CMS goes on to say that a physician face-to-face encounter with the patient is required. Without the physician face-to-face the service must be billed using the NPI of the NPP. CMS gives the example of the physician only reviewing the patient’s medical record as not meeting the shared/split bill requirement resulting in the entire service being bill under the NPP.3

A second example provided by CMS reads “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.”4

A shared/split E/M cannot be used for every POS and it is valid only for select services. “The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and non facility clinic visits, and prolonged visits associated with these E/M visit codes).5 In a non-facility POS the shared/split E/M is billed as “incident to”. For example a shared/split E/M cannot be used when providing a critical care service. “A split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) cannot be reported as a critical care service. Critical care services are reflective of the care and management of a critically ill or critically injured patient by an individual physician or qualified non-physician practitioner for the specified reportable period of time. Unlike other E/M services where a split/shared service is allowed the critical care service reported shall reflect the evaluation, treatment and management of a patient by an individual physician or qualified non-physician practitioner and shall not be representative of a combined service between a physician and a qualified NPP.”6 Additionally the shared/split E/M is not allowed in skilled nursing facilities (SNF).

The office POS is one of those locations where the shared/split E/M cannot be used. However you have “incident to” available to you where you did not have it available in a facility POS. “Incident to” is a little more complicated than shared/split E/M services because there are more regulations to follow.

Physician direct supervision

Physician direct supervision is one regulation you should be aware because “You do not have to be physically present in the treatment room while the service is being provided, but you must be present in the immediate office suite to render assistance if needed. If you are a solo practitioner, you must directly supervise the care. If you are in a group, any physician member of the group may be present in the office to supervise.”7

Additionally the physician must perform the initial service and must remain actively involved in the care and treatment of the patient. Only when all the “incident to” rules are met can you bill using the physician’s NPI.

As with all procedures when billing “incident to” or shared/split E/M services ensure the radiology report and the medical record is documented appropriately for both the combined services and the supervision. The purpose of this article is to make you aware of additional billing opportunities for your NPPs and not intended to be all inclusive or POS locations or regulation.

1SE0441 Page 1. Incident to (PDF, 54 KB)
2Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners 30.6.1.B Shared/split E/M (PDF, 1 MB)
5Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners 30.6.1.H
6Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners 30.6.1.E.1
7SE0441 Page 2

Author - Male

About the author

Nicholas Parish of Compliance – Radiology, McKesson Business Performance Services.