Happy New Year! 2024 brings changes concerning the necessary documentation for split or shared visits. Just a reminder, split or shared visits involve faculty and an APP furnishing an E/M service on the same date for the same problem. This service may be furnished together, at different times of the day, and may or may not include overlapping time where both providers saw the patient together. The provider with substantive portion will be the billing provider.
For most split or shared visits, the APP sees the patient and documents the visit, and the faculty follows. The faculty will be required to enter a substantive portion statement to either claim or not claim substantive portion for the visit. Substantive portion is defined as completing and documenting the MDM to support the level billed or more than 50% of the combined total time spent engaged in patient management on the same calendar date as the face-to-face visit. If the faculty is claiming substantive portion based on MDM, the faculty is required to document their MDM to support the level billed.
Chief Medical Information Officer Carlos Clark, DO, created a new dot phrase (.sharesplitvisit) to assist with this documentation. Please see his email from Jan. 2, 2024, which includes a tip sheet. The dot phrase allows the faculty to pull in the problems address and other relevant information and includes space for faculty to include the required documentation of the plan of care for each diagnosis addressed at the encounter. This new dot phrase will work for both outpatient visits and inpatient initial and subsequent hospital care visits.
Lastly, your coder will reach out to you by your preferred method (email or Epic In-basket) if your substantive portion statement is missing relevant information. Timely responses are appreciated to allow for timely filing deadlines to be reached.
Please feel free to reach out to the coding educators if you have any questions concerning split or shared visits. We are happy to help.
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