CMS CY2026 Physician Fee Schedule

Who Gets Billing Credit When a Physician and an APP Share the Visit

Here is the short version. The setting decides the rulebook. In a facility, a shared encounter is a split/shared visit and the substantive portion picks the biller. In your office, the same pairing is governed by incident-to, and the credit follows a completely different set of conditions. Get the place of service wrong and you have picked the wrong rule before anyone even opens the note.

Facility setting Split/Shared visit Bill under whoever performed the substantive portion. Append modifier FS. Governed by 42 CFR 415.140.

Office / non-facility Incident-To Bill under the physician at 100% only when every 42 CFR 410.26 condition is met. No FS modifier.

The layered answer

Two settings, two rulebooks, stacked one layer at a time

Read each stack top to bottom. Same physician, same APP, same patient, same group. The only thing that changed is the place of service, and every layer below it changes with it.

Layer 0 // Setting

Facility

POS 21 · 22 · 19 · 23

The rule

Split/Shared E/M visit. A single E/M provided by a physician and an advanced practice provider in the same group, in a facility, on the same calendar day.

Who can share

Physician plus NP, PA, CNS or CNM in the same group practice. Both must be from the same specialty group for the encounter to combine.

Who bills

The provider who furnished the substantive portion of the visit. That is the pivot everything turns on, and it is defined below.

How credit is decided

More than half of the total time, or a substantive part of the medical decision making. Critical care is time only.

Modifier

FS Required on every split/shared claim line to flag the shared encounter.

Payment

Billed under the physician pays at the full rate. Billed under the APP pays at 85% of the fee schedule.

Layer 0 // Setting

Office / Non-Facility

POS 11

The rule

Incident-To. Services furnished by auxiliary personnel as an integral part of the physician's professional service, in the office. Split/shared does not apply here.

Who can share

Physician establishes care; the APP or clinical staff delivers the follow-up under supervision. It never covers a new patient or a new problem.

Who bills

The supervising physician's NPI, at 100%, only when every condition holds. Otherwise bill directly under the APP.

How credit is decided

Not by time or MDM. By conditions: established plan of care, direct supervision, active physician involvement, employed or contracted staff.

Modifier

none No FS. The claim simply carries the physician as the rendering provider.

Payment

A qualifying incident-to claim pays at the physician's full rate. Miss a condition and it drops to the 85% APP rate, or it is not payable at all.

The pivot · facility only

"Substantive portion" is a fork, not a stopwatch

For CY2026, CMS keeps the definition it set in the CY2024 Physician Fee Schedule final rule. In a split/shared visit you satisfy the substantive portion by either path. You choose the one that reflects what actually happened, and you document it.

Path A

More than half the total time

Add the physician's and the APP's face-to-face and non-face-to-face time for the day. Whoever crossed the midpoint bills the visit.

physician 58% · APP 42% → physician bills

Path B

A substantive part of the MDM

Whoever performed the substantive part of the medical decision making bills, independent of the clock. Tie the elements of MDM to the provider who owned them.

MDM ownership → that provider bills

⚠

Critical care is the exception. For 99291 and 99292, the substantive portion is time only. Path B is off the table. The MDM route never applies to critical care split/shared visits.

Side by side

The two rulebooks on one line each

Print this and tape it to the coder's monitor. The first question is never "who did more work." It is "where did the visit happen."

Dimension	Split / Shared	Incident-To
Setting	Facility (hospital, on/off-campus outpatient, ED, SNF)	Office and other non-facility (POS 11)
Regulation	42 CFR 415.140	42 CFR 410.26
Who bills	Provider who did the substantive portion	Supervising physician, under conditions
Deciding factor	Time over 50% OR substantive MDM	Plan of care + supervision + involvement
New patient / new problem	Allowed; whoever meets the substantive portion bills	Not permitted; physician must have initiated care
Supervision	Both providers in the same group, same day	Direct supervision: physician in the office suite, immediately available
Modifier	FS on the claim line	None; physician is rendering provider
Payment when correct	Full rate under physician, 85% under APP	Full physician rate

Multispecialty walkthrough

Same patient, same day, three doors, three answers

A regional multispecialty group sees a patient with heart failure and new foot pain. Watch how the billing credit moves as the patient walks between settings and specialties. Archetypes only, no real patients.

Cardiology, hospital floor

The APP rounds first, the cardiologist sees the patient later and owns the medication decisions. Facility setting, so split/shared applies.

→ MDM route: bill under cardiologist, modifier FS

Cardiology, office follow-up

Two weeks later, established plan, the NP handles the stable recheck with the cardiologist supervising on site. POS 11.

→ Incident-to: bill under cardiologist, no FS

Podiatry, office, new problem

Same visit, the patient raises brand new foot pain the physician never evaluated. New problem breaks incident-to instantly.

→ Bill directly under the APP at 85%

Critical care, ICU transfer

The patient decompensates. Physician and APP split critical care time in the facility. Only the clock counts here.

→ Time only: whoever crossed 50% bills, FS

Where groups leak revenue and invite takebacks

The five mistakes we see across multispecialty books

85%

of the fee schedule is what a misfiled claim collects when it lands under the APP instead of the physician. That gap compounds across every shared encounter.

is the single modifier that separates a clean split/shared claim from a denial. Missing or wrongly applied, it is an easy audit flag.

regulations, one per setting. 415.140 for facility, 410.26 for office. Mixing them is the root cause of most disputes we untangle.

POS

Filing incident-to from a facility place of service. Incident-to lives in the office only. A hospital or outpatient POS on an incident-to claim is a rule collision that does not survive review.

NEW PT

Billing a new patient or new problem incident-to. The physician must have personally initiated care and set the plan. A first visit, or a fresh diagnosis, cannot ride under the physician.

SUPERV

No physician in the suite. Direct supervision means the physician is present in the office and immediately available. "On call from home" does not satisfy it for standard incident-to services.

TIME

Choosing the time path when MDM tells the truth. In a split/shared visit you may pick either path, but the record has to support the one you billed. Document the substantive portion, do not assume it.

CRIT

Using the MDM route for critical care. 99291 and 99292 are time only. Any MDM-based split of critical care between a physician and an APP is built on the wrong rule.

Cited by name

The 2026 authorities this page rests on

CMS CY2026 Physician Fee Schedule Final Rule

Retains the split/shared substantive-portion definition: more than half the total time, or a substantive part of the medical decision making, with critical care measured by time only.

42 CFR 415.140

The split/shared visit regulation. Defines the facility E/M shared between a physician and an NPP in the same group and the substantive-portion billing standard.

42 CFR 410.26

Services and supplies incident to a physician's professional service. Sets the direct-supervision, plan-of-care, and non-facility conditions for incident-to billing.

Modifier FS · CMS claims guidance

The "split or shared evaluation and management visit" modifier. Required on split/shared claim lines to identify the shared encounter to the payer.

CMS place-of-service code set

Facility versus non-facility POS drives which rulebook applies. POS 11 signals office incident-to; facility codes signal split/shared.

Medicare Claims Processing & Benefit Policy Manuals

Operational detail on incident-to supervision, the APP 85% payment differential, and split/shared documentation expectations.

Where ASP-RCM fits

Multispecialty billing is where these rules quietly break

When one group runs cardiology, podiatry, primary care and a dozen APPs across hospitals and offices, the split/shared and incident-to logic has to be encoded, not remembered. ASP-RCM Solutions builds the place-of-service and provider-attribution edits into your multispecialty-group billing workflow, so every shared visit routes to the correct rulebook, carries the right modifier, and lands under the right NPI at the right rate. We catch the 85% leaks before they post, not on the audit.

Bring us one month of shared-visit claims and we will show you exactly where the credit is going to the wrong provider.

Talk to our multispecialty billing team →

This article summarizes federal billing rules for operational planning and is not legal, coding, or reimbursement advice. Verify current requirements against the CMS CY2026 Physician Fee Schedule final rule, 42 CFR 415.140, 42 CFR 410.26, and your Medicare Administrative Contractor and payer policies before adjusting billing practices. Scenarios use archetypes, not real patients or clients.