CurrentUnitedHealthcarePolicy 2026R5025A

CMS 1500 claim reporting for incident-to and split/shared E/M services

Defines UnitedHealthcare reimbursement rules for services billed on the CMS‑1500 (or electronic equivalent) including incident-to services in office/clinic settings and split/shared evaluation and management (E/M) services in facility settings for UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 claim reporting for incident-to and split/shared E/M services

Policy CodePolicy 2026R5025A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionReport incident-to services under the supervising provider's NPI when criteria are met and append SA modifier for qualifying advanced practice provider services; append -FS for split/shared E/M visits and allocate payment to practitioner performing the substantive portion.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS 1500form to which policy applies

Commercial + Exchangeplan types covered

-FSsplit/shared identifier

POS 11office POS excluded

>50% time

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substantive portion defined

Reimbursement Criteria

Reimbursement criteria for incident-to and split/shared E/M services

Covered when ALL of the following conditions for incident-to or split/shared E/M services are satisfied as specified below.

ALL of the following

ALL of the following
- An integral, although incidental, part of the Supervising Health Care Provider's services.
- Commonly rendered without separate charge or included in the Supervising Health Care Provider's bill.
- Of a type commonly furnished in the Supervising Health Care Provider's office or clinic.
- Provided under direct personal supervision — Supervising Health Care Provider present in the location of service and immediately available throughout the time services are performed.
- Services rendered by a Nonphysician Provider that meet incident-to criteria should be reported under the Supervising Health Care Provider's NPI.
- Services rendered by an Advanced Practice Health Care Provider that meet incident-to criteria should be reported under the supervising physician's NPI and the SA modifier appended.

ALL of the following

Split/shared visits permitted in facility settings when both a physician and an NPP in the same group perform parts of the visit and the service could be billed independently by either practitioner.
Modifier -FS must be reported on claims to identify split/shared E/M visits.
Office or other outpatient E/M services (Place of Service 11) are not eligible to be billed as split/shared services.

Substantive portion determination

Key component: one of the three key E/M components (history, exam, or medical decision-making) performed in its entirety by the billing practitioner; when a key component is used, the billing practitioner must perform that component in full to bill that level.
Time: the practitioner who performs more than half of the total combined time spent by the physician and NPP performing the visit (counting qualifying activities) is considered to have performed the substantive portion.

Qualifying time activities that may be counted toward total time (when performed and whether or not involving direct patient contact): preparing to see the patient; obtaining/reviewing separately obtained history; performing exam/evaluation; counseling/education; ordering medications/tests/procedures; referring/communicating with other professionals when not separately reported; documenting clinical information; independently interpreting results not separately reported and communicating results; care coordination not separately reported. Excluded: services reported separately, travel, and general teaching not required for management of a specific patient.

ALL of the following

Prolonged services: when combined time of both practitioners meets prolonged thresholds, the practitioner reporting the primary service may report prolonged services (setting-specific thresholds apply).
Critical care: split/shared critical care allowed; substantive portion defined as more than half of the cumulative total qualifying critical care time (CPT 99291/99292); practitioner must devote full attention during critical care periods and cannot provide services to other patients during those periods.
When a separate E/M is provided on the same calendar date as critical care, both may be billed if documentation shows the E/M occurred prior to critical care, was medically necessary, and is separate and distinct; use modifier -25 when applicable.

ALL of the following

Payment is made to the practitioner who performed the substantive portion of the split/shared visit.
Modifier -52 (reduced services) cannot be used to report partial E/M visits, including split/shared visits.

Modifiers, Time Thresholds, and Definitions for Coding

Modifiers referencedModifier

-FS	CPT modifier to identify split/shared E/M visit
SA	Modifier appended when Advanced Practice Health Care Provider services that meet incident-to are reported under supervising physician NPI
-25	Modifier for same-day E/M distinct from critical care

Split/shared identifierModifier

-FS	CPT modifier to identify split/shared E/M visit

Incident-to modifierModifier

SA	Modifier appended when Advanced Practice Health Care Provider services that meet incident-to are reported under supervising physician NPI

Same-day separate E/M modifierModifier

-25	Modifier for same-day E/M distinct from critical care

Prolonged services time threshold (non-office/outpatient)

Threshold60 or more minutes beyond the typical CPT time descriptor for the primary service (applies to prolonged E/M services other than office/outpatient)

Applicable settingsAll E/M visits except emergency department and critical care (ED and critical care are not reported as prolonged)

Combined time ruleWhen split/shared visits use a key component as the substantive portion, prolonged services may be reported when the combined time of both practitioners meets the threshold

Reporting practitionerProlonged services are reported by the practitioner who reports the primary service when combined time meets threshold

Substantive portion time threshold

Definition

Billing and Reporting Guidance for Providers

Billing Rule

Split/shared billing and modifier

Report split/shared evaluation and management (E/M) visits with modifier -FS to indicate the service was a split (or shared) visit. The practitioner who performed the substantive portion of the visit is the one eligible to bill and receive payment.

Split/shared visits are allowed for new and established patients and for initial and subsequent visits when requirements are met.
The substantive portion is either one of the three key E/M components (history, exam, or medical decision-making) or more than half of the total time spent by the physician and advanced practice professional (NPP).
When a key component is used as the substantive portion, the billing practitioner must perform that component in its entirety at the level billed. If the component is split between practitioners, the practitioner billing must have performed the full component required to select the visit level.
If time is used as the substantive portion, the practitioner who spends more than half of the total combined time performs the substantive portion and may bill.
Do not use CPT modifier -52 to report partial E/M visits or partial services furnished as split/shared visits; use modifier -FS.

Key Definitions

Advanced Practice Health Care Provider

DefinitionNon-physician licensed practitioner such as PA, NP, or CNS who may bill directly under applicable state law

Role in split/sharedMay perform portions of E/M visits that contribute to determining the substantive portion

Incident-to billingAdvanced Practice Health Care Provider services may be reported under a supervising physician NPI with SA modifier when incident-to criteria are met

Supervising Health Care Provider

DefinitionPhysician or advanced practice provider with their own NPI who is responsible for supervising services

Billing responsibilitySupervising provider's NPI is used for incident-to billing when criteria for incident-to are met

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 claim reporting for incident-to and split/shared E/M services

Policy CodePolicy 2026R5025A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

Substantive portion = one of the three key E/M components (history, exam, or MDM) or more than half of the total combined practitioner time

Time thresholdMore than half of the total combined time spent by the physician and NPP performing the visit

Component ruleIf a key component is used as the substantive portion, the billing practitioner must perform that component in its entirety

Critical care noteFor critical care visits, substantive portion is defined as more than half of the cumulative total critical care time

Billing Rule

Split/shared prolonged services

Prolonged services associated with split/shared visits follow the guidance below based on the type of E/M visit and the substantive portion used.

For shared hospital outpatient visits where a key component is the substantive portion, prolonged services may be reported by the practitioner who reports the primary service when the combined time of both practitioners meets the CPT threshold for prolonged hospital outpatient services.
For all other types of E/M visits (except emergency department and critical care visits), prolonged services may be reported by the practitioner who reports the primary service when the combined time of both practitioners meets the threshold for reporting prolonged E/M services other than office/outpatient E/M visits (60 or more minutes beyond the typical time in the CPT code descriptor of the primary service).
Emergency department and critical care visits are not reported as prolonged services.

Supervision contextMust meet direct personal supervision requirements where applicable for incident-to services

Facility Setting

DefinitionInstitutional setting where incident-to billing is prohibited under CMS regulations (Facility Setting)

Split/shared applicabilitySplit (or shared) E/M visits are allowed in Facility Settings when both physician and NPP in same group perform parts of the visit

Office exclusionOffice or other outpatient (Place of Service 11) visits are not eligible to be billed as split/shared services

Nonphysician Practitioner

DefinitionIncludes physician assistants (PA), nurse practitioners (NP), and clinical nurse specialists (CNS) as nonphysician practitioners legally authorized under state law

RoleNPPs may perform and bill independently for services where authorized and may participate in split/shared visits

Group contextWhen in the same group as a physician, services performed by NPPs can contribute to substantive portion determination

Nonphysician Provider

DefinitionAuxiliary personnel such as nurses and medical assistants acting under supervision; may include advanced practice providers when applicable

SupervisionNonphysician providers perform tasks under the supervision of a physician or Advanced Practice Health Care Provider

Billing implicationThese personnel are not the same as Nonphysician Practitioners (NPPs) who may bill independently under state law

Substantive Portion

DefinitionSubstantive Portion = the history, exam, MDM, or more than half of the total combined time spent by the practitioners; for critical care, defined as more than half of cumulative critical care time

Qualifying activitiesIncludes history, exam, MDM and qualifying time activities counted toward total time for substantive portion determination

Billing requirementPractitioner who performed the substantive portion is eligible to bill and must perform the chosen key component in its entirety if used