What Is Split/Shared Billing and How Does It Work?

Split/shared billing is a mechanism in healthcare that allows for the proper compensation of services when multiple healthcare professionals collaborate in patient care. This approach is particularly relevant in team-based care models, where a collective effort delivers comprehensive services to individuals. It ensures that the contributions of different providers are appropriately accounted for in the billing process. This system reflects the evolving nature of healthcare delivery, emphasizing coordinated care.

Defining Split and Shared Billing

Split and shared billing refers to evaluation and management (E/M) services where a physician and a non-physician practitioner (NPP) jointly provide care to a patient. The core principle distinguishing these services is the “substantive portion” of the visit, which dictates which provider can bill for the service.

For services rendered on or after January 1, 2024, the Centers for Medicare & Medicaid Services (CMS) defines the “substantive portion” as either more than half of the total time spent by the physician and NPP, or a substantive part of the medical decision-making (MDM). Previously, during 2022 and 2023, the substantive portion could also be determined by performing one of the three key E/M components: history, examination, or medical decision-making. The current definition consolidates this to time or MDM, reflecting updated Current Procedural Terminology (CPT) guidelines.

When determining the substantive portion by time, the total time spent by both the physician and the NPP on the patient’s care on the calendar date of the encounter is combined. This includes both face-to-face and non-face-to-face activities. If medical decision-making is the determinant, the provider who made or approved the management plan and assumes responsibility for its inherent risks is considered to have performed the substantive portion.

Context of Service Delivery

Split and shared billing specifically applies to services provided in facility settings, such as hospitals (inpatient, outpatient, and emergency departments) and skilled nursing facilities. This billing method acknowledges the collaborative efforts of physicians and non-physician practitioners within these institutional environments. It does not apply to services rendered in non-facility settings, like physician offices, where different “incident-to” billing rules typically govern team-based care.

Non-physician practitioners include Physician Assistants (PAs), Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and Certified Nurse Midwives (CNMs). These practitioners often work closely with physicians, either under supervision or in a collaborative arrangement, to deliver comprehensive patient care. Their roles allow for increased access to care and efficient management of patient caseloads within a healthcare system.

A common scenario involves an NPP initiating a patient encounter, gathering information, and performing preliminary assessments. A physician then reviews the case, adds their expertise, and contributes to the overall care plan. This collaborative approach allows for efficient patient flow and leverages the distinct skills of various healthcare professionals. Such team-based care models are increasingly prevalent, necessitating clear billing guidelines.

Billing and Documentation Requirements

Accurate billing for split and shared services depends on clearly identifying the provider who performed the “substantive portion” of the evaluation and management (E/M) visit. As defined by the Centers for Medicare & Medicaid Services (CMS) for services on or after January 1, 2024, this determination is based on either more than half of the total time spent by the physician and NPP, or a substantive part of the medical decision-making (MDM). This updated guidance streamlines the process for determining the billing provider. Proper documentation is crucial to support this determination.

When time is the basis for determining the substantive portion, all distinct time spent by both the physician and the NPP on the patient’s care on the day of the encounter is summed. This includes activities such as:

• Preparing to see the patient
• Reviewing tests
• Obtaining history
• Performing examinations
• Counseling
• Ordering medications or procedures
• Communicating with other healthcare professionals
• Documenting clinical information
• Interpreting results

If both practitioners are involved in a joint activity, such as a direct discussion with the patient, that time can only be counted once towards the total.

For situations where medical decision-making determines the substantive portion, the physician or NPP who bills the service must document their active role in the complex decision-making process. The documentation should clearly support their contribution to the plan, referencing clinical findings and diagnostic interpretations.

The medical record must explicitly identify both the physician and the NPP who contributed to the visit. The provider who performed the substantive portion and will bill for the service must sign and date the medical record. For time-based billing, it is also important to document the time spent by each contributing provider to justify the substantive portion determination.

All claims for split and shared services must include the HCPCS modifier -FS. This modifier signals to payers that the service was a collaborative effort between a physician and an NPP. Payment for these services is made to the practitioner who performed the substantive portion of the visit.

Medicare generally reimburses services billed under a physician’s National Provider Identifier (NPI) at 100% of the fee schedule, whereas services billed under an NPP’s NPI are reimbursed at 85%. This difference in reimbursement rates underscores the financial implications of correctly identifying the substantive portion and the billing provider. Providers must ensure their documentation supports the chosen billing method to avoid compliance issues. Critical care services can also be billed as split or shared visits, with the substantive portion always determined by time.