Top 5 Audit Tips for Split/Shared Visits

Auditing Split/Shared Visits? Start Here First.

Article Reference Code: NAMAS.11.28.2025

Written by: Sonda Kunzi, CPC COC CPB CRC CPCO CPMA CPPM CPC-I

Auditing split/shared encounters can get messy and not because auditors lack the regulation text. CPT and CMS have made the rules clear enough. What creates confusion is where the audit starts. If you begin with documentation instead of first asking the right operational question “Where was this patient?” you risk applying the wrong rule set. That single question determines whether split/shared or incident-to regulations apply.
The heart of both billing concepts is location-dependent, and each follows its own compliance framework for how services are delivered and billed. It’s time to shift how we approach these audits so we’re not just checking boxes but truly applying CPT and CMS intent to keep providers compliant and documentation defensible.

Audit Tip #1 Confirm if split shared is even allowed before reviewing the note

• CMS defines split shared as an E&M service performed by a physician and an NPP in a facility setting.
• Under 42 CFR §413.65, only formally designated provider-based departments qualify as hospital outpatient institutional locations for split shared.
• Hospital owned practices in so called “outpatient settings” function under office style incident to logic if not designated as provider based.

Don’t feel like you have to get too far into the weeds on this first tip, sometimes you know the group you are auditing, and provider-based location isn’t an issue. There’s certainly more to consider.

Audit Tip #2 Distinguish SNF from NF to apply the correct rule set

• CMS states that nursing facility (NF) visits do not meet the definition of split/shared services because incident to payment is available in the NF setting as CMS considers that location non-facility.
• A Medicare skilled SNF bed may allow split shared billing, except when a physician only E&M service is required. (Initial comprehensive SNF visit)
• Two patients can be in the same building but perhaps on different floors under different statuses, so the bed type and designation must be confirmed in the audit process. Your providers need to communicate the right location of care.
  • Audit review must confirm SNF skilled bed status versus NF bed status before classifying a service as split shared.

Audit Tip #3 Confirm required CMS documentation elements before substantive portion review

• The record must identify both the physician and the NPP who performed the visit.
• The individual who performed the substantive portion (i.e. billing provider) must sign and date the medical record.
• One of the two practitioners must have face to face in person contact with the patient, but it does not have to be the billing practitioner.

Audit Tip #4 If time is used, test distinct minutes and CMS qualifying activities

• Count only distinct time. When both practitioners are present or discussing the patient, count only one provider’s time.
• Qualifying time activities may include preparing to see the patient, reviewing history, medically appropriate evaluation, counseling on medications, ordering tests, communicating with other professionals, and documenting.
• Do not count travel, services eligible to be separately billed or general teaching.
• For prolonged services and critical care, the substantive portion must be more than fifty percent of total time.

Audit Tip #5 When MDM is used, look for evidence that the billing practitioner had substantive engagement in medical decision-making

• CMS allows the substantive portion to be determined by MDM only in E&M code families where MDM is an eligible option, such as inpatient, hospital outpatient, ED and SNF services.
• When MDM is used instead of time, the billing practitioner must be clearly tied to the medical decision-making process, not just mentioned in the encounter or listed as a co-signer.
• Look for documentation that shows the billing practitioner assessed the problems, ordered or reviewed tests, made treatment decisions or documented risk considerations. If the NPP documented the entire plan and the physician only added “agree with above,” that does not establish substantive MDM by the physician.
• Notes that state “Seen by NP, reviewed with physician, physician will bill” do not meet CMS expectation for MDM-based substantive portion.
  CMS requires that the medical record reflect the billing practitioner’s own involvement in the decision-making elements used to select the code level.

Red flag: The claim is billed under the physician, but the physician’s only entry is an attestation or signature confirming agreement. Without documentation of substantive engagement in MDM, evidence needed for split shared billing under the physician is not supported.

In Conclusion
Auditing split/shared encounters touches every part of compliance for documentation, operations, and how providers and auditors interpret the “substantive portion” of the service. The key is to start with structure and end with evidence: the right setting, clear documentation showing who performed the substantive portion, and proof that it supports the billed service. When Medicare or a commercial payer follows CMS split/shared regulations, modifier FS must appear on the claim to identify that the visit was split/shared. That combination of accurate billing and defensible documentation is what keeps providers compliant and audit results consistent.

Reference(s):
CMS MLN Booklet Evaluation and Management Services MLN006764 September 2025 pages 21 through 23. https://www.cms.gov/files/document/mln006764-evaluation-management-services.pdf
Regulations in 42 Code of Federal Regulations (CFR) 413.65 describe the criteria and procedures for determining whether a facility or organization is provider-based. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-413/subpart-E/section-413.65

If you have questions about this article or it’s content- Click here to connect with Sonda on LinkedIn

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Coding Advantage, LLC started with Sonda teaching the Certified Professional Coder (CPC) classes at night in a local hospital in 2013. The company grew organically through providing additional certification courses for practice management and medical auditing. From a one-person start to a team of experts serving clients nationwide, our growth reflects our commitment to excellence in coding, auditing, and compliance.

 

 

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