What are the changes in the CMS split shared visit guidelines for 2026?

For CY 2026, CMS has maintained alignment with CPT guidelines for split (or shared) Evaluation and Management (E/M) visits, meaning there are no sweeping structural overhauls to the core policy, but the established standards remain strictly enforced.

Key Guidelines and Continuing Standards for 2026

• Definition of the Substantive Portion: The substantive portion of a split/shared visit (in a facility setting like a hospital or skilled nursing facility) is defined as more than half of the total time spent by the physician and non-physician practitioner (NPP) combined, or performing a substantive part of the medical decision-making (MDM).
• Setting Limitations: Split/shared visits continue to apply only to institutional/facility settings (such as inpatient, emergency departments, or SNFs), not to traditional private office settings (Place of Service 11), where "incident-to" rules apply instead.
• Time Calculation: When calculating time, joint or overlapping time spent together by both practitioners can only be counted once toward the total cumulative time.
• Documentation & Signatures: The medical record must explicitly identify both individuals who performed the service. The practitioner who performed the substantive portion (and under whose NPI the service is billed) must sign and date the medical record.
• Required Modifiers: Claims must still append the -FS modifier to designate a split/shared E/M service.

Medicare defines a split/shared visit as an Evaluation and Management (E/M) encounter in a facility or institutional setting where a physician and a non-physician practitioner (NPP) from the same group practice jointly provide care.

Core Policy Rules

• Substantive Portion: The practitioner who performs the "substantive portion" of the visit must bill for the service. Under CMS guidelines, the substantive portion means spending more than half of the total time or performing a substantive part of the medical decision-making (MDM).
• Eligible Settings: This policy applies strictly to institutional/facility settings (such as hospital inpatient, outpatient, observation, or emergency departments) where "incident-to" billing is prohibited. It does not apply to traditional, non-facility private office settings.
• Face-to-Face Requirement: At least one of the practitioners must have face-to-face contact with the patient, though it does not have to be the specific provider who bills the service.
• Billing and Modifiers: The claim must be submitted under the National Provider Identifier (NPI) of the practitioner who performed the substantive portion. You must append the FS modifier on the claim form.
• Documentation: The medical record must clearly identify both participating providers. The note must be signed by the billing practitioner, and simple co-signatures or generic agreement statements are not sufficient.

The CMS coding updates for 2026 include quarterly HCPCS Level II adjustments, instructional note revisions for ICD-10-CM, and new procedure and technology code sets.

Key 2026 CMS Coding Changes

• ICD-10-CM April 2026 Updates: Introduced instructional note changes rather than sweeping code additions, converting multiple Excludes1 notes to Excludes2 notes to make sequencing encounter-dependent.
• ICD-10-CM FY 2026 Annual Updates: Featured 614 new codes (including expanded non-pressure chronic ulcer specificity, new diabetes in remission codes, and laterality distinctions for abdominal/pelvic pain) effective for the broader 2026 tracking period.
• HCPCS Level II Quarterly Updates: Regular updates throughout 2026—including the October quarterly changes—adjust code tables, supply lists, and drug codes (such as home health consolidated billing non-routine supply additions).
• ICD-10-PCS: Ongoing additions for new medical technologies and inpatient procedures effective through early 2027 discharge windows.

You can review complete, searchable documentation directly through the CMS ICD-10 Coding Guidelines and the HCPCS Quarterly Update resource pages.

CMS incident-to billing allows services provided by auxiliary staff or non-physician practitioners to be billed under a supervising physician's National Provider Identifier (NPI) at 100% of the Medicare Physician Fee Schedule rate instead of an NPP's standard 85% rate.

Core 2026 Requirements

• Noninstitutional Setting: Must occur in an office or clinic, not a hospital or skilled nursing facility.
• Established Patient/Plan: The supervising physician must first perform an initial service and establish the diagnosis and treatment plan. New patients or new problems do not qualify for incident-to billing on the initial visit.
• Direct Supervision Update: Effective January 1, 2026, CMS permanently allows real-time, two-way audio-video interactive telecommunications to satisfy direct supervision requirements for most services, meaning the physician does not always need to be physically in the office suite, though audio-only does not qualify.
• Exclusions: Services with global surgery indicators of 010 or 090 (10-day or 90-day global periods) are excluded from virtual direct supervision and require physical presence.
• State Law: Staff members must act within their permitted state scope of practice and employment relationship to the billing physician.

Yes, two providers from the same practice can bill on the same day, but it depends entirely on their medical specialties and whether the services are for related or unrelated conditions.

Same Specialty vs. Different Specialties

• Same Specialty: Insurance rules—including Medicare guidelines via the Centers for Medicare & Medicaid Services—generally treat providers of the exact same specialty in the same group practice as a single provider. If they perform separate Evaluation and Management (E/M) visits for the same or related problems on the same day, you must combine the work into a single E/M code. They can only bill separately if the visits are for completely unrelated problems that require separate, distinct encounters.
• Different Specialties: Providers in the same practice (under the same Tax ID) who belong to different specialties (such as an internal medicine doctor and a cardiologist) can bill separate same-day E/M visits or procedures. The services must be distinct, medically necessary, and supported by separate medical records using appropriate diagnosis codes.

Best Practices for Billing Same-Day Claims

• Distinct Documentation: Ensure each provider creates a separate, thorough medical record proving the unique necessity of their visit.
• Use Modifiers Correctly: Append required modifiers (such as Modifier 25 for a significant, separately identifiable service) when billing multiple codes on the same date.
• Check Payer Guidelines: Review specific commercial insurance or Medicare Administrative Contractor (MAC) policies, as rules for concurrent care and same-day billing vary by region and plan.