Split/Shared Visit Billing for Behavioral Health Practices: 2026 Rules and Revenue Impact

Background: How Split/Shared Visit Rules Evolved

Split/shared visits have existed as a billing concept for decades, but CMS significantly revised the rules starting with the CY 2022 Physician Fee Schedule final rule. Before 2022, the long-standing guidance (based on CMS Teaching Physician guidelines and Medicare Claims Processing Manual, Chapter 12) required the physician to be present for a "face-to-face" portion of the encounter. In practice, this meant the physician had to see the patient, but the threshold for how much of the visit the physician needed to perform was ambiguous.

The CY 2022 PFS final rule formalized the split/shared visit definition: an E/M visit where a physician and an NPP (nurse practitioner or physician assistant) each personally perform a substantive portion of the encounter on the same day, for the same patient, in a facility setting. CMS defined "substantive portion" as one of the key components (history, exam, or MDM) or more than half of the total time. The visit would be billed under the NPI of the practitioner who performed the substantive portion.

CMS then proposed that beginning in CY 2024, the substantive portion would be defined solely by time: the practitioner who performed more than half of the total time would bill the service. This proposal was delayed in the CY 2024 PFS final rule, delayed again in the CY 2025 final rule, and remains delayed for CY 2026. The current rule retains the dual-method approach: either time or key element can determine the substantive portion.

This regulatory back-and-forth matters for behavioral health practices because the time-only rule would have a disproportionate impact on psychiatric practices where an NP spends 30-40 minutes providing psychotherapy and the psychiatrist spends 10-15 minutes reviewing medications and making treatment decisions. Under a time-only rule, those visits would always bill under the NP's NPI at the lower rate. Under the current rule, the psychiatrist can be the billing provider if they performed the key element of MDM.

How Split/Shared Visits Work in Behavioral Health

Behavioral health practices use team-based care models that create natural split/shared visit scenarios. Understanding which encounters qualify and which do not is critical for both revenue optimization and compliance.

Psychiatrist + NP Medication Management Visits

The most common behavioral health split/shared scenario is a psychiatric visit in a facility setting where the NP conducts the intake assessment, reviews the patient's history, and provides a psychotherapy or counseling component, and the psychiatrist then evaluates the patient, reviews the NP's findings, performs medical decision-making for medication management, and finalizes the treatment plan. If the psychiatrist performs the substantive portion (either more than half the total time, or the key element of MDM), the visit is billed under the psychiatrist's NPI at the physician rate.

Team-Based Care in PHP, IOP, and Residential Settings

Partial hospitalization programs (PHP), intensive outpatient programs (IOP), and residential treatment facilities frequently use team-based models where NPs and PAs provide significant portions of patient care under physician oversight. In these facility settings (POS 19, 21, 22), split/shared billing can be applied to daily E/M encounters where both the physician and the NPP participate in the patient's care on the same day.

For residential treatment facilities billing daily E/M services, the difference between billing under the physician NPI versus the NP NPI across all patients and all days of stay can represent a substantial revenue difference. However, each encounter must be independently documented and must reflect the actual substantive portion determination for that specific day.

Shared Psychiatric Evaluations

Initial psychiatric evaluations in hospital-based settings can also qualify as split/shared visits when the NP performs the comprehensive history and preliminary assessment, and the psychiatrist performs the diagnostic formulation and treatment planning. However, the psychiatric evaluation codes (90791, 90792) are not E/M codes and therefore fall outside the formal CMS split/shared visit framework. When both providers contribute to what is essentially an evaluation visit, practices need to determine whether to bill the encounter as a split/shared E/M visit (using 99221-99223 or 99202-99215 depending on the setting) or as a psychiatric evaluation under one provider's NPI.

Emergency Department Psychiatric Consultations

Emergency departments (POS 23) qualify for split/shared billing. When a psychiatric NP performs the initial psychiatric assessment of a patient in the ED and the consulting psychiatrist subsequently evaluates the patient, reviews findings, and makes disposition decisions, the resulting E/M service can be billed as a split/shared visit under the provider who performed the substantive portion.

Facility vs. Non-Facility: A Critical Distinction

One of the most common billing errors in behavioral health is attempting to apply split/shared visit rules in non-facility settings. This is a hard boundary: split/shared visits only apply in facility settings.

Qualifying behavioral health facility settings include:

• Hospital-based outpatient behavioral health clinics (POS 22): Outpatient psychiatry and psychology clinics that operate as departments of a hospital and bill under the hospital's provider number.
• Partial hospitalization programs (POS 19 or 22): PHP programs operated by a hospital, whether on-campus or off-campus.
• Inpatient psychiatric units (POS 21): Psychiatric inpatient floors within general hospitals or freestanding psychiatric hospitals.
• Residential treatment facilities (POS 21 or 22): Depending on how the facility bills, residential programs may qualify when they use facility-based billing and the appropriate POS code.
• Emergency departments (POS 23): Psychiatric consultations in hospital emergency departments.

If your behavioral health practice operates in a freestanding outpatient setting (POS 11), the physician and NP should each bill for their own independently identifiable E/M service when appropriate, or the rendering provider should bill the encounter under their own NPI. "Incident-to" billing is the relevant framework for non-facility team-based billing, which has its own separate requirements.

Revenue and Financial Impact

The financial impact of split/shared visit billing in behavioral health is substantial and worth quantifying for any practice that operates in facility settings with both physicians and NPPs.

Revenue optimization considerations:

• Workflow design: Structure physician-NP workflows so that the physician consistently performs the MDM component when clinically appropriate. If the physician is performing substantive medical decision-making (reviewing diagnostic data, determining medication changes, assessing risk), the visit can legitimately be billed under the physician NPI even if the NP spent more total time with the patient.
• Time tracking discipline: If using the time-based method, accurate time tracking is essential. An undocumented claim that the physician spent more than half the time will not withstand an audit. Both providers should record their start and stop times for each encounter.
• Code level impact: The rate differential applies at every E/M code level. Higher-level E/M codes (99215, 99223) have larger absolute dollar differences between physician and NPP rates. Practices should ensure they are coding to the appropriate level for all split/shared visits, not just using 99213 by default.
• Payer variation: Medicare's split/shared visit rules are specific to Medicare. Medicaid programs and commercial payers may have different rules for team-based billing. Some state Medicaid programs do not recognize split/shared visits. Some commercial payers follow Medicare rules; others have their own policies. Verify payer-specific rules before applying split/shared billing across your full payer mix.

Documentation Requirements

Documentation is where split/shared visit billing succeeds or fails in audits. CMS expects that the medical record for a split/shared visit clearly demonstrates which portions each practitioner performed and supports the substantive portion determination.

Required Documentation Elements

• Both providers must document: Each practitioner must have a separate note or a clearly delineated section within a shared note describing the services they personally performed. A single note with a co-signature and no delineation of who did what is insufficient.
• Time documentation (if using time-based method): Each provider must document the time they individually spent on the encounter. Total time includes all qualifying activities: reviewing records, discussing the case with the other provider, taking history, performing exam, MDM, care coordination, and counseling with the patient. Time documentation must be specific (e.g., "I spent 22 minutes on this encounter") rather than vague.
• MDM documentation (if using key element method): If the physician is billing the visit based on performing the key element of medical decision-making, the physician's documentation must demonstrate the MDM performed, including the complexity of problems addressed, data reviewed, and risk of the management decision. The documentation must be substantive enough to support the MDM level selected for billing.
• Identification of the billing provider: The note should clearly indicate which provider is billing the service and the basis for that determination (time or key element).
• Same-day, same-patient requirement: Documentation must reflect that both providers saw the same patient on the same calendar day. If the NP sees the patient in the morning and the physician sees the patient in the afternoon, both encounters should be documented and linked.

Documentation Pitfalls

These are the documentation errors that consistently cause split/shared visit denials and audit findings:

• Clone documentation: Notes where both providers appear to have documented the same services, or where one provider's note is a copy of the other's, will trigger audit scrutiny and suggest that only one provider actually performed the services.
• Missing provider identification: Notes that do not clearly identify which services each provider performed. "Patient seen by NP and Dr. Smith" without further delineation is not sufficient.
• Undocumented time claims: Asserting that the physician spent more than half the total time without documenting the specific time for each provider. Time must be documented contemporaneously, not reconstructed after an audit inquiry.
• Billing under the wrong NPI: Billing under the physician NPI when the NP clearly performed the substantive portion based on the documentation. This is not just a billing error; it is a false claims risk.

Common Errors and Audit Risks

OIG and MAC audits of split/shared visits have increased in recent years as CMS has refined the rules. These are the most frequent findings:

1. Applying split/shared rules in office settings (POS 11). This is the most common error. Practices that operate in freestanding outpatient offices cannot bill split/shared visits. If both a physician and an NP see the patient in a POS 11 setting, the visit must be billed under the rendering provider or under incident-to rules if applicable. Billing a split/shared visit in POS 11 will result in recoupment on audit.
2. Insufficient documentation of who performed what. Split/shared visits require documentation from both providers. A single note with a co-signature does not establish that both providers personally performed portions of the service. Auditors look for two distinct contributions documented in the medical record.
3. Billing under the physician when the NP performed the substantive portion. This creates False Claims Act liability. If the documentation shows the NP spent 35 minutes and the physician spent 8 minutes, and the key element of MDM was routine medication refills requiring low-complexity decision-making, billing under the physician NPI is not defensible. The billing must match the documentation.
4. Confusing split/shared visits with incident-to billing. These are different frameworks with different rules. Incident-to billing applies in non-facility settings and requires the physician to be present in the office suite (though not in the room). Split/shared visits apply in facility settings and require both providers to personally perform portions of the service. Using the wrong framework leads to billing errors in either direction.
5. Not verifying payer-specific rules. A practice that applies Medicare split/shared rules to a Medicaid claim in a state that does not recognize split/shared visits will have that claim denied or recouped. Always verify the specific payer's policy.

What Your Billing Team Needs to Do

Implementing compliant and optimized split/shared visit billing requires coordination between clinical operations, provider education, and RCM workflow design. These are the priority action items:

1. Identify which services qualify for split/shared billing. Audit your current service mix to determine which encounters involve both a physician and an NPP seeing the same patient on the same day in a facility setting. Quantify the volume and revenue impact. Focus on facility-based E/M services (99202-99215, 99221-99223, 99231-99233) provided in POS 19, 21, 22, and 23.
2. Implement documentation templates for split/shared visits. Work with your clinical and EHR teams to create note templates that prompt each provider to document their individual contribution, time spent, and the substantive portion determination. The template should make it easy for each provider to document their portion and difficult to submit a note that omits required elements. EHR platforms like AZZLY Rize and PIMSY support collaborative note templates that facilitate compliant split/shared visit documentation.
3. Train providers on time tracking. If your practice uses the time-based method for substantive portion determination, providers must track and document their time for each split/shared encounter. Implement time-tracking tools within the EHR or provide simple time-logging worksheets. Training should emphasize that time includes all qualifying activities, not just face-to-face time with the patient.
4. Build pre-billing review for split/shared claims. Before submitting split/shared visit claims, the billing team should verify that the documentation supports the billing provider assignment, that the place of service is a qualifying facility setting, and that both providers have documented their portions. This review can be built into the charge entry workflow or the claim scrubbing process.
5. Audit current split/shared claims for compliance. Conduct a retrospective audit of split/shared visits billed in the past 12 months. Check for claims billed in non-facility settings, claims where documentation does not support the billing provider assignment, and claims where time documentation is absent or insufficient. Correct any identified issues and use the findings to refine your prospective process.
6. Create a payer-specific split/shared visit policy matrix. Document each major payer's split/shared visit rules, including whether they follow Medicare guidelines, whether they recognize the key element method, and whether they impose additional documentation requirements. This matrix should be accessible to billing staff and updated when payer policies change.
7. Monitor CMS rulemaking for the time-only proposal. CMS has repeatedly proposed and delayed a rule that would define the substantive portion solely by total time. If this rule is finalized in a future PFS cycle, it will significantly affect behavioral health practices where the physician's contribution is primarily MDM rather than time-intensive. Monitor the annual PFS proposed and final rules and plan for potential workflow changes. See our CMS 2026 PFS analysis for additional context.

EHR and Technology Implications

Your EHR system plays a central role in enabling compliant split/shared visit billing. The following capabilities are essential for practices that regularly bill split/shared services.

• Collaborative note templates: The EHR should support multi-provider documentation within a single encounter, with clearly delineated sections for each provider's contribution. Each section should be independently authored and authenticated by the respective provider. EHR platforms like AZZLY Rize provide structured collaborative note templates designed for team-based psychiatric encounters, ensuring that both providers document their portions in a compliant format.
• Time tracking by provider: The EHR should capture time-in and time-out for each provider participating in a split/shared visit. This time tracking should be integrated into the note template so that time documentation is captured as part of the clinical workflow rather than as an afterthought. Automated timers are preferable to manual entry for audit defensibility.
• Split/shared billing automation: The billing module should support logic that identifies split/shared visit encounters, prompts the user to designate the billing provider based on the substantive portion determination, and applies the correct NPI and rate to the claim. Automated alerts that flag potential errors (such as a split/shared visit in a non-facility POS) prevent compliance issues before claim submission.
• Audit reporting: The EHR should generate reports on split/shared visit volume, billing provider distribution (physician vs. NPP), revenue impact, and documentation completeness. These reports enable ongoing compliance monitoring and revenue optimization analysis.
• POS validation: The system should validate that the place of service for a split/shared visit claim is a qualifying facility setting (POS 19, 21, 22, or 23) and alert users if a non-qualifying POS is selected.

For detailed guidance on behavioral health billing codes and E/M coding, including code selection for split/shared encounters, see our comprehensive billing codes guide.

Frequently Asked Questions

What is a split/shared visit in behavioral health?

A split/shared visit is an E/M service where both a physician (such as a psychiatrist) and a non-physician practitioner (such as a psychiatric NP or PA) each personally perform a substantive portion of the visit for the same patient on the same day in a facility setting. The visit is billed under the NPI of the practitioner who performed the substantive portion. This model is common in behavioral health settings where psychiatrists and NPs collaborate on patient care, with the NP handling therapy or assessment components and the psychiatrist focusing on medication management and medical decision-making.

Can split/shared visits be billed in outpatient office settings?

No. CMS split/shared visit rules apply only in facility settings: POS 19 (off-campus outpatient hospital), POS 21 (inpatient hospital), POS 22 (on-campus outpatient hospital), and POS 23 (emergency department). Freestanding outpatient psychiatric offices (POS 11) do not qualify. Practices operating in non-facility settings should bill under the rendering provider's own NPI using standard E/M coding or, where applicable, under incident-to rules, which have their own separate requirements.

How is the "substantive portion" determined for split/shared visits in 2026?

The current 2026 rules allow two methods. Under the time-based method, the practitioner who spends more than half the total time on the visit bills the service. Under the key element method, the practitioner who performs the key or critical portion of the visit (history, physical exam, or medical decision-making) bills the service. CMS had proposed moving to a time-only definition but has delayed that proposal. For behavioral health practices where the psychiatrist's primary contribution is MDM, the key element method often supports billing under the physician NPI even when the NP spent more total time with the patient.

What is the revenue difference between billing a split/shared visit under a physician versus an NP?

Medicare reimburses NPs and PAs at 85% of the physician fee schedule rate, creating an approximately 15% rate differential. For a 99214 in a facility setting, this is roughly $17 per visit. For a practice performing 50 split/shared visits per week, properly billing under the physician NPI when the physician performs the substantive portion generates approximately $44,000 more per year. For larger organizations with multiple physician-NP teams, the annual impact can exceed $200,000 to $400,000. The billing must accurately reflect which practitioner performed the substantive portion; attributing the visit to the physician when the NP performed the substantive portion is a compliance violation.

What documentation is required for split/shared visits?

Both the physician and the NPP must document the portions of the visit they personally performed. Documentation must clearly identify each practitioner's contribution, including time spent if using the time-based method. The medical record must support which practitioner performed the substantive portion. Both providers should sign or authenticate their respective portions. A single note with co-signatures is acceptable only if it clearly delineates who performed which elements. Vague documentation like "patient seen by NP and physician" without further specifics will not survive an audit.

How do split/shared visit rules apply to psychiatric evaluations and psychotherapy add-on codes?

Split/shared visit rules apply to E/M services (CPT 99202-99215 and inpatient equivalents). Psychiatric diagnostic evaluations (90791, 90792) and psychotherapy add-on codes (90833, 90836, 90838) are not E/M codes and fall outside the formal CMS split/shared visit framework. When a psychiatrist and an NP both contribute to what is functionally an evaluation visit, practices should determine whether to bill as a split/shared E/M visit or as a psychiatric evaluation under one provider's NPI. Consult your compliance team on the appropriate coding for team-based psychiatric encounters that combine E/M and non-E/M services.

Editorial Standards

Last reviewed: February 26, 2026

Methodology

• CMS CY 2022-2026 Physician Fee Schedule final rules reviewed for split/shared visit policy evolution and current requirements
• Medicare Claims Processing Manual (Chapter 12) reviewed for E/M billing guidelines applicable to split/shared visits
• OIG audit reports and MAC audit findings analyzed for common split/shared visit compliance issues
• AMA CPT coding guidance reviewed for E/M code selection in team-based encounters

Primary Sources

• CMS CY 2026 Physician Fee Schedule Final Rule
• CMS: Split (or Shared) Visits
• Medicare Claims Processing Manual, Chapter 12
• AMA: CPT Evaluation and Management (E/M) Code and Guideline Changes
• Federal Register: CY 2024 PFS Final Rule - Split/Shared Visit Delay