Split/shared evaluation and management services get attention

The Centers for Medicare & Medicaid Services (CMS) is issuing a friendly reminder to be careful when coding patient visits that involved services from both a physician and a non-physician provider.

In the latest Medicare Quarterly Provider Compliance Newsletter, a publication designed to help avoid common billing errors and other erroneous activities when dealing with Medicare, CMS focused on split/shared evaluation and management (E/M) services.

As CMS notes, a split/shared E/M services is an encounter in which a physician and a non-physician provider (NPP), such as a nurse practitioner or physician assistant, each personally performs a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. This is not uncommon in family medicine.

Unfortunately, CMS and its auditors have identified such visits as a source of common billing errors, most often because of insufficient documentation errors. More specifically, there was insufficient documentation to support that both the physician and NPP performed a substantive portion of the split/shared E/M service. CMS offers the following example:

A split/shared E&M claim was submitted for payment. While the submitted documentation contained a physician's signature on the NPP's clinical note, no other documentation was made by the physician supporting that the physician performed a substantive portion of the split/shared E&M service. This claim was scored an improper payment due to an "insufficient documentation error."

Proper documentation of split/shared E/M services plays into whether the service is billed under the physician's national provider identifier (NPI) or that of the NPP. That, in turn, affects the level of payment, since Medicare typically pays services billed under an NPP's NPI at a rate less than what it pays a physician for the same service.

For more information beyond the newsletter, CMS encourages you to look at Chapter 12, Section 30.6, of the Medicare Claims Processing Manual and Chapter 15, Section 60, of the Medicare Benefit Policy Manual. You can also view the Evaluation and Management Services Guide on the CMS website.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians