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Are You Coding Split/Shared Visits and Incident-To Services Correctly?
Educational Blog | Updated August 2026
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Split/shared visits generally apply in facility settings.
Incident-to billing generally applies in the physician office
or clinic setting when every Medicare requirement is met.
When a physician and a nonphysician practitioner participate in a patient's care,
deciding who should bill the service is not always simple. Two Medicare billing
concepts that are frequently confused are split/shared visits and incident-to services.
Although both involve services performed by more than one healthcare professional,
they apply in different settings and have different billing, supervision, and
documentation requirements. Understanding the difference is essential for compliant
coding and accurate reimbursement.
A split/shared visit is an evaluation and management service performed jointly by a
physician and a qualified nonphysician practitioner, such as a nurse practitioner
or physician assistant.
- Are performed in a facility setting, such as a hospital or qualifying nursing facility.
- Involve a physician and nonphysician practitioner from the same group.
- Require both practitioners to perform a medically necessary portion of the visit.
- Are billed by the practitioner who performs the substantive portion.
- Require modifier FS on the claim.
CMS defines the substantive portion as either more than half of the combined total
time spent by the physician and nonphysician practitioner, or a substantive part of
the medical decision making as defined by CPT guidelines.
For prolonged E/M services and other services selected strictly by time, the billing
practitioner must perform more than half of the combined qualifying time. Overlapping
time cannot be counted twice.
The documentation should clearly identify the work performed by each practitioner and
support why the billing practitioner performed the substantive portion of the encounter.
The practitioner billing the service must sign and date the medical record.
Evaluation and Management Services
and performs the examination. The physician later evaluates the patient, analyzes the
test results, determines the diagnosis, and develops the treatment plan.
If the documentation supports that the physician performed the substantive portion of
the medical decision making, the service may be billed under the physician's NPI with
modifier FS.
A physician's signature or a statement such as "I agree with the nurse practitioner's
note" does not automatically demonstrate that the physician performed the substantive
portion. A cosignature alone is not sufficient.
Incident-to billing generally applies to services provided in a physician's office or
clinic as part of an established course of treatment. The service may be performed by
qualified auxiliary personnel or a nonphysician practitioner and billed under the
supervising physician or practitioner when all Medicare requirements are met.
- Be an integral, although incidental, part of the patient's normal course of treatment.
-
Follow an initial professional service personally performed by a physician or other
qualified billing practitioner. - Be furnished as part of an established treatment plan.
-
Be provided while the physician or practitioner remains actively involved in the
patient's care. - Meet the applicable supervision requirement.
- Be commonly furnished in an office or clinic.
- Represent an expense to the billing practice.
- Be permitted under state law and the individual's scope of practice.
When incident-to requirements are satisfied and the service is billed under a physician's
NPI, Medicare generally reimburses the service at 100% of the physician fee schedule.
When a qualified nonphysician practitioner bills a service under their own NPI, Medicare
generally reimburses it at 85% of the physician fee schedule.
Incident-To Services and Supplies
Incident-to billing generally should not be used when the nonphysician practitioner
evaluates a new patient, addresses a new problem, or makes a significant change to
the established treatment plan without the required physician or billing practitioner
involvement.
If a new condition is identified during an incident-to visit, the practice should
determine whether:
-
The physician or qualified practitioner must personally evaluate the patient and
establish the new treatment plan, or - The nonphysician practitioner should bill the service under their own NPI.
The goal should always be compliant billing — not simply obtaining the higher
reimbursement rate.
plan. At a later office visit, a nurse practitioner evaluates the patient's response to
the medication and continues the established plan. The supervising practitioner is
available as required, and all other incident-to conditions are met. The follow-up
service may qualify for incident-to billing.
However, if the patient reports new chest pain and the nurse practitioner evaluates
and treats that new condition, the service may no longer meet incident-to requirements.
The physician may need to personally evaluate the new problem and establish the treatment
plan, or the nurse practitioner may need to bill under their own NPI.
| Requirement | Split/Shared Visit | Incident-To Service |
|---|---|---|
| Primary Setting | Facility | Office or clinic |
| Participants | Physician and qualified NPP | Physician, NPP, or auxiliary personnel |
| Patient's Condition | May involve a new or established problem | Generally follows an established treatment plan |
| Billing Provider | Practitioner performing the substantive portion | Supervising physician or qualified practitioner when all requirements are met |
| Required Modifier | FS | No specific Medicare incident-to modifier |
| Physician Signature Alone Sufficient? | No | No |
| Main Documentation Focus | Who performed the substantive portion | Established plan, active involvement, supervision, and who performed the service |
For 2026, Medicare's definition of direct supervision may allow the supervising physician
or practitioner to be virtually present through real-time audio and video technology for
services that do not have a 010- or 090-day global surgery indicator. Audio-only
availability does not satisfy this requirement.
Practices should verify whether the specific service qualifies and confirm any additional
payer, state-law, or scope-of-practice requirements.
CY 2026 Medicare Physician Fee Schedule correction
- Billing a hospital visit as incident-to.
- Reporting a split/shared service without modifier FS.
- Billing under the physician simply because the physician cosigned the note.
- Failing to identify the work personally performed by each practitioner.
- Counting overlapping physician and NPP time twice.
- Billing incident-to for a new patient or new problem without the required practitioner involvement.
- Failing to document the supervising practitioner.
- Assuming every payer follows Medicare's incident-to or split/shared rules.
- Was the service performed in a facility or an office setting?
- Did both the physician and nonphysician practitioner personally participate?
- Who performed the substantive portion of the split/shared visit?
- Does the documentation clearly support each practitioner's work?
- Was modifier FS appended when required?
- For incident-to billing, was an established treatment plan already in place?
- Did the visit address only established problems under that plan?
- Was the required supervision available and documented?
- Does state law permit the individual to perform the service?
- Does the patient's payer follow Medicare's billing rules?
The location of the service is often the fastest way to determine which billing concept may apply:
Evaluate whether the service qualifies as a split/shared visit.
Evaluate whether the service meets incident-to requirements.
Never select the billing provider based solely on who signed the note. The documentation
must support who performed the service, who made the medical decisions, whether the required
supervision was available, and whether every payer-specific requirement was satisfied.
Correct billing begins with understanding the setting, the work performed,
and the documentation.
Do not simply choose the NPI that produces the highest reimbursement.
This article focuses primarily on Medicare fee-for-service requirements.
Medicare Advantage plans, Medicaid programs, and commercial payers may
establish different policies. Always verify the individual payer's guidelines
and applicable state scope-of-practice laws.
- CMS: Evaluation and Management Services
- CMS: Incident-To Services and Supplies
- CMS Medicare Benefit Policy Manual, Chapter 15
- Federal Register: CY 2026 PFS Correcting Amendments
For more coding education, CPC exam tips, and medical coding training:
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