Split/Shared Visits: Who Bills and Who Gets the wRVU Credit

What a split/shared visit actually is

A split/shared visit occurs when a physician and a non-physician practitioner (NPP) — a nurse practitioner (NP) or physician assistant (PA) — who belong to the same medical group both personally perform part of the same evaluation and management (E/M) service for the same patient on the same calendar date in a facility setting.

The phrase "personally performed" carries real weight here. Simply signing a note, placing a phone order, or reviewing a chart remotely does not count as performing a portion of the visit. Each clinician must be physically present and provide a distinct part of the face-to-face encounter or the associated documentation work for the visit to qualify as split/shared.

Because two clinicians contributed care but Medicare pays for a single service, CMS has a specific rule for which practitioner's National Provider Identifier (NPI) goes on the claim. That choice determines who receives the Medicare payment — and, in most physician employment contracts, which provider gets the wRVU credit.

Where the rules apply — and where they don't

Split/shared billing is a facility-only framework. It covers services delivered in settings identified by these place-of-service (POS) codes:

• Inpatient hospital (POS 21)
• Hospital emergency department (POS 23)
• Hospital outpatient department (POS 19 and 22)
• Ambulatory surgical center (POS 24)
• Skilled nursing facility (POS 31 and 32)
• Other inpatient and residential facility codes as applicable

The rule does not apply to a freestanding outpatient physician office (POS 11). When a physician and an NP or PA see the same patient in a private-practice clinic, a different set of billing rules governs the encounter — most commonly incident-to billing or separate billing under the APP's NPI. This guide focuses on the split/shared framework that matters for hospitalists, intensivists, surgical teams, emergency providers, and others working in facility-based settings.

The substantive portion test: two pathways to bill

The billing practitioner must be the one who performed the substantive portion of the visit. Under the CY 2024 Physician Fee Schedule final rule, which remained in effect unchanged through CY 2026, there are two ways to establish the substantive portion:

Pathway 1 — Time

The billing practitioner personally spent more than half of the total combined visit time on that calendar date. "Total time" follows the standard E/M time definition: it includes the billing clinician's own face-to-face time with the patient, time reviewing records, placing orders, and writing documentation. Joint face-to-face time with the patient can only be counted once. The comparison is between each clinician's own documented time; the billing practitioner must account for more than 50% of the combined figure.

Pathway 2 — Medical Decision Making (MDM)

The billing practitioner personally performed the substantive portion of the MDM. Under current CPT guidelines, this means the clinician developed or approved the assessment and plan of care and personally assumed overall responsibility for the patient's management. Performing individual MDM elements — reviewing lab results, entering orders, noting the patient's history — without taking that overall responsibility does not satisfy this pathway.

One important exception

For critical care (the time-based codes used for unstable or critically ill patients) and for prolonged service add-on codes, only the time pathway applies. There is no MDM alternative for these code families.

Documentation and modifier requirements

Regardless of which pathway applies, the medical record must identify both practitioners and what each one contributed. Each clinician documents the portion they personally performed; the billing practitioner signs and dates the record. On the claim, modifier FS must be appended to the E/M code to tell Medicare the service involved a split/shared encounter.

How the billing choice reshapes your wRVU total

This is where the financial impact becomes tangible. When the physician bills, Medicare pays at 100% of the physician fee schedule rate. When the NPP bills, the payment drops to 85% of the physician fee schedule. The difference flows through to your practice's collections — but that is not the part most physicians focus on.

What hits physicians directly is wRVU attribution. In the vast majority of production-based compensation contracts, wRVU credit follows the billing NPI. If the NPP is the billing practitioner for an encounter, the NPP receives the wRVU credit and the physician receives none — even if the physician was the one who settled on the diagnosis and signed off on the clinical plan.

To put concrete numbers on it: a typical hospital admission for a complex patient might generate approximately 3.5 wRVUs (99223 for a high-complexity new inpatient admission). At a $45/wRVU rate, that single encounter is worth roughly $157.50 in compensation credit. If the NPP bills 40 such encounters per month that would otherwise go to the physician, the physician loses about $6,300 per month — or more than $75,000 annually — in attributed production, without any change in actual workload.

The volume of shared encounters varies widely. Hospitalists and academic inpatient teams often have the highest exposure because APP collaboration is built into the workflow. Physicians who have not confirmed how their group handles split/shared attribution may be leaving wRVU credit on the table without knowing it.

A worked example

Suppose Dr. Alvarez (a hospitalist) and an NP from the same group both evaluate a newly admitted patient with a pulmonary embolism. The NP performs the initial history and physical and documents 28 minutes of total time. Dr. Alvarez sees the patient, reviews the imaging, adjusts the anticoagulation plan, and documents 20 minutes of total time.

Under the time pathway: combined time is 48 minutes; the NP's 28 minutes exceed 50%. The NP is the billing practitioner, and the NP receives the wRVU credit.

Under the MDM pathway: Dr. Alvarez specifically documented that she personally developed the assessment and treatment plan and assumed ongoing responsibility for the patient's management. She qualifies as the billing practitioner under MDM, and she receives the wRVU credit.

Both outcomes are legally valid billing choices. The one that applies depends entirely on what the documentation supports. If neither practitioner documented the MDM responsibility explicitly, the time pathway is the only option — and whichever clinician spent more than half the time is the one who bills.

What your employment contract should say

CMS rules govern who bills Medicare. They do not mandate how employers allocate wRVUs internally for compensation purposes. That means the answer to "who gets my wRVU credit on a split/shared encounter" is a contract term, not a federal regulation. Common employer approaches:

• Billing NPI = all the wRVU credit: the most common default, and the one that creates the largest swings in physician production when NPPs bill frequently.
• Proportional allocation: the physician and NPP split the wRVU based on each clinician's documented share of the combined time. Requires more accounting but avoids all-or-nothing outcomes.
• Physician always receives a floor share: some groups guarantee the physician a minimum credit (say, 50%) on any encounter in which the physician was personally present, regardless of who billed.

Before signing a contract in a setting where split/shared encounters are common, ask specifically:

1. How does the group attribute wRVUs on split/shared encounters — billing NPI, proportional split, or something else?
2. Is the wRVU threshold in my contract calibrated for the actual mix of personally billed vs. shared encounters in this role?
3. Does the contract distinguish "personally performed wRVUs" (required for some quality and bonus metrics) from "attributed wRVUs" that include shared-encounter allocations?

Silence on this point typically defaults to the billing-NPI model, which is worth naming explicitly so both parties understand the financial stakes of workflow design.