More than one provider involved in care, nomenclature considerations

Anyone who has parsed through the CY 2026 Physician Fee Schedule Final Rule, which was published in the Federal Register on Nov. 5, 2025, can attest that the material is dense. Moreover, a variety of topics are addressed.

One topic that caught the attention of many was the concept of “split/shared.” While preparing for a couple of presentations, I found myself asking what the best way is to explain the concept, as well as distinguish it from “incident to” billing. Both “split/shared” and “incident to” involve more than one provider rendering services to the same patient, often simultaneously. So, what is the difference?

First, the Centers for Medicare and Medicaid Services (CMS) describes “incident to” as follows:

• Incident to services and supplies are those provided as an integral, although incidental, part of the physician’s or nonphysician practitioner’s personal professional services during diagnosis and treatment. Physicians, Nurse Practitioners (NPs), Certified Nurse-Midwives (CNMs), Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) are nonphysician practitioners who are authorized to have services provided by auxiliary personnel.
• NPs, CNMs, CNSs, and PAs may enroll in, and get payment from us, for “incident to” services and supplies provided by auxiliary personnel that they supervise. Additionally, NPs, CNMs, CNSs, and PAs only have the option of providing services as auxiliary personnel incident to the professional services of a supervising physician or nonphysician practitioner. States cover and pay under the incident to provision, when services and supplies comply with applicable state law and meet all these requirements:
  • Are an integral part of the patient’s normal treatment when the physician or other listed practitioner personally performed an initial service and remains actively involved in the course of treatment.
  • Are commonly provided without charge or included in the physician’s or other listed practitioner’s bill.
  • Are an expense to the physician or other listed practitioner.
  • Are commonly provided in the physician’s or other listed practitioner’s office or clinic.
  • Physician or other listed practitioner provides direct supervision for the “incident to” services, and only the physician or other listed practitioner who supervises the incident to services may bill them.
  • We require general supervision by a physician or other listed practitioner when clinical staff have services and supplies provided incident to Transitional Care Management (PDF) and Chronic Care Management (PDF). Only the supervising physician or other listed practitioner may bill services and supplies incident to TCM and CCM services. Additionally, we require general supervision by a physician or other listed practitioner for behavioral health services provided by auxiliary personnel incident to the professional services of a physician or other listed practitioner.

Second, CMS defines “split/shared” as a “visit is an E/M visit that both a physician or NPP in the same group perform in a facility setting, and in accordance with applicable law and regulations, either the physician or NPP can bill the service if they provide it independently. We pay the practitioner who performs the substantive portion of the visit.”

When deciding whether services are eligible for split/shared services or incident to billing, there are several factors that need to be taken into consideration:

1. Location
   1. Split/shared services take place in the facility setting, and excludes office visits and nursing facilities.
   2. Incident to billing takes place in the clinic or office setting.
2. Billing Provider
   1. Split/shared services are billed out under the clinician providing the substantive portion (majority of total time, or substantive part of medical decision-making) of the E/M.
   2. Incident to services are rendered by the non-physician practitioner who is following an established plan of care, under the direct supervision of the billing physician.
3. Services Rendered
   1. Split/shared services are only applicable to E/M services.
   2. Incident to billing is applicable to services and supplies that are part of the patient’s normal course of treatment.
4. Physician Involvement
   1. Split/shared services are when both physician and non-physician practitioners participate in the rendering of the E/M service.
   2. Incident to services do not require that the physician personally render a service. The physician is immediately available and provides direct supervision (present in the office suite to render assistance as needed). The physician’s ongoing participation in the patient’s care must also be documented.

This area is material because it can lead to upcoding, which in-turn can violate the False Claims Act. Ensuring that billers and coders are up to date on the CY 2026 PFS, which is effective Jan. 1, 2026, and that software is not automatically set to code a certain way are important prophylactic measures that can mitigate the risk of running afoul of the billing and coding requirements.

Rachel V. Rose, J.D., MBA, advises clients on compliance, transactions, government administrative actions, and litigation involving health care, cybersecurity, corporate and securities law, as well as False Claims Act and Dodd-Frank whistleblower cases. She also teaches bioethics at Baylor College of Medicine in Houston. Rose can be reached through her website, www.rvrose.com.