NPP Billing: Know When to Use Incident-To Vs. Split/Shared Billing

It’s no secret that more and more practices are using skilled non-physician practitioners (NPPs) to provide efficient and patient-centered care – and why shouldn’t they? A 2014 Medical Group Management Association (MGMA) analysis reports that 68 percent of highly functioning practices employed NPPs. And with NPPs available to perform at least 80 percent of primary care services with equal or greater patient satisfaction than an actual physician, according to Care Cloud, it’s easy to see why this practice is so common.

But here’s the catch: as you know, NPP services billing can be tricky. Use incident-to billing for cases needing split/shared billing, or vice versa, and you’ll face claims denials and ire from the Office of the Inspector General (OIG), explains LaTrece Freeman-Baker in her live webinar with ProfEdOnDemand. During her presentation To Bill or Not to Bill: Physicians Working with NPPs, Freeman-Baker lays out different scenarios for each type of billing, as well as the documentation you need, so you have the information necessary for proper billing and compliance purposes.

Look at Who Performed the Services

To start clarifying the issue, here are a few key definitions:

  • Non-physician practitioner: A licensed, non-physician healthcare professional who is still able to perform many, but not all, services provided by a physician. The most common examples of NPPs are nurse practitioners and physician assistants
  • Incident-to billing: Services that are integral, although incidental, to a patient’s treatment program and are provided by an NPP. These services must meet certain requirements to be covered by Medicare.
  • Split/shared billing: You should bill for a split/shared evaluation and management (E/M) visit when “the physician and a qualified NPP each personally perform a substantive portion of an E/M face-to-face with the same patient on the same day of service,” according to the Medicare Claims Processing Manual Publication 100-04, chapter 12, section 30.6.1.H Split/Shared E/M Visit. “A substantive portion of an E/M visit involves all or some portion of the history, exam, or medical decision-making key components of an E/M service.”

2 Elements Required for Split/Shared Billing

So you get the basics: bill for incident-to when the NPP performed all the services, and for split/shared services when the visit was split by the NPP and the physician. Seems far too simple, doesn’t it? Again, the key factor in proper billing is  documentation.  For successful claims, and to fight back against claims denials, make sure all required elements are present in the documentation before billing.

To bill for split/shared services, these two key elements must be present in the visit record:

  • Documentation of the face-to-face portion of the E/M visit; and
  • Clear identification of which services that the NPP performed and which the physician performed.


Not only must the documentation clearly state who performed which services, but the NPP must be the one to document the services she performed and the doctor must do the same. It’s not enough for the NPP to write everything that happened, and the doctor to merely sign and date or write “as above” in the medical record. The Wisconsin Physicians Service Insurance Corporation provides other examples of when you cannot bill for split/shared services, which include:

  • “Patient seen,” “Seen and examined and agree with above,” or a similar variation written, then signed by the physician;
  • “The patient was seen and examined by myself and Dr. Z, who agrees with this plan,” written by the NPP and then signed by the physician; and
  • No documentation or signature at all from the physician.


Be Careful: Without these two elements, you won’t be able to bill for split/shared services, but you might not be able to bill for incident to, either. Always check the documentation requirements before automatically assuming incident-to services.

Documentation Dictates Billing

With coding and billing, it always comes down to the documentation. If you have what you need, you can argue against wrongful claim denials. In contrast, says Freeman-Baker, you can never bill for something you don’t have evidence for in the records. Take a few minutes today to grasp all the requirements to avoid running into any issues later!

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