Navigating Split Billing: What Multispecialty Practices Need to Know

In today’s value-based care environment, multispecialty practices are expanding rapidly—offering patients access to a variety of services under one roof. While this model enhances patient care and convenience, it also introduces complexities into the billing process, particularly when it comes to split billing.

Split billing, though essential in many scenarios, is often misunderstood. When not handled properly, it can lead to billing errors, denials, compliance issues, and lost revenue. This blog provides a comprehensive guide to help multispecialty providers understand, manage, and optimize split billing in a compliant and efficient way.

What Is Split Billing?

Split billing occurs when different components of a patient’s visit are billed to different payers or billing entities, or when services are rendered by multiple providers within the same visit but require separate claim submissions.

Common scenarios for split billing:

• A facility fee is billed by the hospital, while the professional fee is billed by the physician.
• A Medicare patient receives a preventive service covered under Part B, while a procedure is billed to Part A.
• A patient sees both a primary care physician and a specialist in one visit, requiring separate bills.
• Workers’ compensation covers one service, while the patient’s health insurance covers another.
• A telehealth service is billed separately from in-person diagnostic testing done the same day.

Why Split Billing Is Important for Multispecialty Practices

Multispecialty practices often combine various services such as:

• Internal medicine
• Pediatrics
• Cardiology
• Orthopedics
• Behavioral health
• Diagnostic testing (imaging, labs)

As these services may fall under different payer contracts, or involve distinct provider types with their own National Provider Identifier (NPI), split billing becomes essential to ensure:

• Accurate reimbursement
• Regulatory compliance
• Transparency in charge capture
• Financial sustainability

Key Elements of a Split Billing Workflow

To effectively navigate split billing, multispecialty practices must manage a combination of clinical, operational, and financial components. Here’s what the ideal workflow includes:

1. Clear Documentation at the Point of Service

Providers must clearly document the distinct nature of each service provided. For instance:

• A cardiology consult must be documented separately from a physical therapy session on the same day.
• Time-based services (e.g., psychotherapy, prolonged visits) must meet the minimum required duration and reflect that time in the encounter note.

2. Proper Use of Modifiers

Modifiers help clarify that multiple services are distinct and billable. Common ones include:

• Modifier 25: Significant, separately identifiable E/M service by the same provider on the same day as another procedure.
• Modifier 59: Distinct procedural service.
• Modifier 91: Repeat clinical diagnostic laboratory test.

Failure to use the right modifier can lead to claim denials or bundling errors.

3. Understanding Payer Rules

Different payers may have different interpretations of when and how split billing is allowed. Medicare, Medicaid, and commercial payers often vary in:

• Documentation requirements
• Acceptable modifiers
• Reimbursement policies

Always verify payer-specific policies using:

• Payer portals
• Provider manuals
• Pre-bill audits

4. Segregated Charge Capture

Make sure that each department/provider documents and submits distinct charges. For instance:

• The orthopedic department submits CPT 99213 for a follow-up visit.
• The radiology department submits CPT 73562 for a knee X-ray.

Each charge must be attributed to the correct rendering provider and NPI.

5. Multiple Claim Forms When Required

Split billing often requires generating multiple claims:

• CMS-1500 (professional claim)
• UB-04 (institutional/facility claim)

Proper routing of these claims to the respective payers or billing systems is critical.

Split Billing vs. Global Billing: What’s the Difference?

It’s important not to confuse split billing with global billing, especially in surgical and diagnostic scenarios.

Example: A radiologist performs a chest X-ray read (professional component), while the imaging center bills for the equipment use (technical component). This is a classic split billing scenario using modifier 26 (professional) and modifier TC (technical).

Challenges in Split Billing

Despite its benefits, split billing introduces challenges:

1. Risk of Duplicate Billing

When services overlap or are not clearly delineated, payers may flag claims for duplication, leading to audits or recoupments.

2. Coding Errors

Improper use of modifiers, bundling codes, or incorrect CPT/ICD-10 combinations can result in rejections.

3. Compliance Risks

Split billing done incorrectly can violate CMS or payer rules, especially if it appears that the provider is “double dipping” or submitting duplicate charges.

4. Workflow Complexity

Coordinating between different departments, billing teams, and software systems can slow down claim submission and payment timelines.

Best Practices for Managing Split Billing

✅ Establish Standard Operating Procedures (SOPs)

Define clear rules for:

• When to split claims
• How to use modifiers
• Documentation requirements
• Charge entry workflow

✅ Train Staff Across Departments

Educate providers, coders, and billers on split billing rules—especially for high-frequency combinations like E/M + imaging or E/M + procedures.

✅ Use Technology to Automate Workflows

• Integrated EHR and billing platforms can help identify and separate split billing scenarios.
• Use billing rules engines to flag missing modifiers or inconsistent documentation before claims are submitted.

✅ Conduct Internal Audits

Periodically review claims that involve split billing to:

• Catch coding discrepancies
• Track denial rates
• Ensure payer compliance

✅ Coordinate with Your Billing Partner

If you use a third-party billing company, ensure they understand the nuances of multispecialty billing and have experience handling split claims correctly.

Real-World Example

Let’s say a patient visits a multispecialty clinic and receives:

• A general check-up by a family physician (CPT 99214)
• A dermatology consult for a suspicious lesion (CPT 99203)
• A biopsy performed (CPT 11100)

Each service must be:

• Separately documented
• Coded accurately
• Assigned to the correct provider
• Billed to the appropriate payer (e.g., Medicare Part B or commercial insurance)

Failure to split the charges properly could result in underpayment, overpayment, or compliance flags.

Conclusion

Split billing is an essential yet complex component of revenue cycle management for multispecialty practices. When executed correctly, it allows practices to maximize reimbursement, maintain compliance, and deliver high-quality patient care efficiently.

As practices grow and diversify, the need for clear protocols, coding precision, and interdepartmental coordination becomes more important than ever.

At Right Medical Billing, we specialize in navigating the nuances of multispecialty and split billing. Our expert team ensures accurate claim separation, modifier use, and documentation guidance—so you can focus on what matters most: your patients.