Split/Shared Visits in Wound Care: 2026 Billing Rules

Split/Shared Visits in Wound Care: What Changed and What Matters

Split/shared visits in wound care allow a physician and a non-physician practitioner -- typically a nurse practitioner or physician assistant -- to each provide a portion of the same patient encounter and bill under a single claim. CMS has refined these rules significantly since 2022, and the 2026 requirements are now stable enough that wound care practices should be building workflows around them rather than avoiding them.

The core concept: when both a physician and an NPP see the same patient on the same day in the same group practice, the visit is billed under whichever provider performed the "substantive portion." Getting that determination right -- and documenting it correctly -- is the difference between compliant billing and an audit liability.

For practices weighing split/shared against other collaboration models, see Incident-To vs Independent Billing. For the full CPT procedure code reference, see Wound Care CPT Codes 2026.

The Substantive Portion Rule

Under CMS rules, the substantive portion of a split/shared visit is determined by one of the following:

History
Physical exam
Medical decision-making (MDM)
Total time (more than half)

The provider who performs the substantive portion bills the visit. In wound care, this usually comes down to MDM or time.

MDM as the Substantive Portion

If the physician performs the medical decision-making -- reviewing the wound assessment, determining the treatment plan, making prescription decisions, deciding whether to refer for surgical intervention -- the physician performed the substantive portion. The visit bills under the physician's NPI at the physician fee schedule rate.

If the NP performs the MDM -- evaluating the wound, determining that the current treatment plan should continue or be modified, ordering labs or imaging -- the visit bills under the NP's NPI.

Time as the Substantive Portion

When using time, the provider who spends more than half the total time on the encounter performed the substantive portion. Total time includes face-to-face and non-face-to-face activities on the date of the encounter.

Example: An NP spends 20 minutes performing the wound assessment, measuring wounds, and applying dressings. The physician spends 15 minutes reviewing the assessment, examining one wound that concerns them, and adjusting the treatment plan. Total time is 35 minutes. The NP spent more than half. The visit bills under the NP.

If the physician had also spent 10 minutes on care coordination calls after the encounter (25 minutes total), the physician performed the substantive portion and the visit bills at the physician rate.

Split/Shared Visit Documentation Requirements

Both providers must document their individual contributions. This is not optional, and a single note signed by both is not sufficient under current CMS guidance.

What Each Provider Must Document

The NP's documentation should include:

The components of the visit they performed (exam findings, wound measurements, procedures)
Time spent (if using the time-based pathway)
Their clinical assessment and any decisions made within their scope

The physician's documentation should include:

The components they performed (exam, MDM, review of data)
Time spent (if using the time-based pathway)
Their clinical assessment and treatment decisions
A clear statement of their personal involvement

The Billing Provider's Note

The provider who bills the visit should have a note that reflects the level of service billed. If the physician bills a 99214, the physician's documentation must support moderate MDM or 30-39 minutes of total time. The NP's documentation of their portion supplements but does not substitute for the billing provider's own documentation.

Documentation tip: Include a statement like "I personally performed the medical decision-making for this encounter, including review of wound assessment data and modification of the treatment plan" or "I personally spent 25 of the 40 total minutes on the date of encounter."

Split/Shared Visits vs Incident-To in Wound Care

Practices sometimes confuse split/shared billing with incident-to billing. They are different models with different requirements:

Key Differences

Split/shared requires both providers to see the patient. The billing provider is determined by who performed the substantive portion. The visit can occur in any setting (office, facility, home).

Incident-to allows the NP to see the patient independently, billing under the physician's NPI. The physician must have established the plan of care and must be physically present in the office suite (not necessarily in the room). Incident-to is available only in the office setting -- it does not apply to facility, home, or SNF visits.

For wound care practices that operate across multiple settings -- clinic, SNF, home health -- split/shared is often the more practical model because it works everywhere. Incident-to is limited to the office.

When Split/Shared Makes Sense in Wound Care

High-volume wound care clinics where NPs perform initial assessments and the physician reviews complex cases. The physician bills the complex visits at the physician rate; the NP bills straightforward follow-ups independently.
SNF and home-based wound care where incident-to is not available. Split/shared allows physician-rate billing when the physician is involved in care.
Complex wound patients where both the NP's procedural expertise and the physician's diagnostic judgment are clinically necessary on the same visit.

Key Takeaways

The substantive portion determines which provider bills a split/shared visit -- it is based on history, exam, MDM, or whoever spent more than half the total time.
Both providers must independently document their contributions to the encounter; a single co-signed note is insufficient.
Split/shared visits work in all settings (office, facility, SNF, home), while incident-to is restricted to the office.
For wound care practices operating across multiple care settings, split/shared billing offers more flexibility than incident-to for physician-rate reimbursement.
Document time for both providers even when using MDM as the substantive portion, because it preserves the option to use either pathway on audit review.