Expert Article: Documentation of Shared E/M Services

Expert Article: Documentation of Shared E/M Services

Does the attending physician have to document their medical decision making for PA/NP shared E/M services, or must their attestation indicate what elements of the E/M service they provided to support reporting a shared service?

The ED physician may review and approve the PA/NP documentation and attest to their performance of the substantive portion of the MDM. For instance, an ED physician may state:

“I personally made/approved the management plan for this patient and am responsible for the patient management.”

If the assignment of the E/M code relies on Data Category 2 (independent interpretation) and/or Data Category 3 (discussion with an external physician), the ED physician’s documentation should include documentation of their independent interpretation and/or reference to any discussions the ED physician had with external physicians or other sources. In these circumstances, the attestation might also include the independent interpretation or discussion of management.

If the ED physician documents the MDM elements they performed during the encounter, e.g., plan of care, interpretations, medications prescribed, discharge instructions, etc., they are not required to additionally document an attestation. The attestation example provided serves as an alternative to the ED physician having to re-document the plan of care or MDM elements that have already been documented by the PA/NP.

How does CPT define a Split/Shared Visit?

The American Medical Association (AMA) has revised the CPT guidelines regarding “split or shared visits” for 2024. The definition of a “split or shared visit” now refers to the substantive portion of an Evaluation and Management (E/M) service. The revised definition states that the substantive portion is determined either by more than half of the total time spent by the physician and other qualified healthcare professional (QHP) performing the split visit or by a substantive part of the medical decision making (MDM). These guidelines are intended to assist in determining which healthcare provider, the physician or QHP, may bill for the service.

Physician(s) and other qualified health care professional(s) (QHP[s]) may act as a team in providing care for the patient, working together during a single E/M service. The split or shared visits guidelines are applied to determine which professional may report the service. If the physician or other QHP performs a substantive portion of the encounter, the physician or other QHP may report the service.

For the purpose of reporting E/M services within the context of team-based care, performance of a substantive part of the MDM requires that the physician(s) or other QHP(s) made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management. By doing so, a physician or other QHP has performed two of the three elements used in the selection of the code level based on MDM.

If the amount and/or complexity of data to be reviewed and analyzed is used by the physician or other QHP to determine the reported code level, assessing an independent historian’s narrative and the ordering or review of tests or documents do not have to be personally performed by the physician or other QHP, because the relevant items would be considered in formulating the management plan.

Independent interpretation of tests and discussion of management plan or test interpretation must be personally performed by the physician or other QHP if these are used to determine the reported code level by the physician or other QHP.

How does CMS define a Split/Shared Visit?

Recognizing that facility-based services have evolved to a more team-based approach to care, CMS believes that when an E/M service is shared between a physician and a PA/NP (which CMS refers to as nonphysician practitioner or NPP) in the same group, there is close coordination and an element of collaboration in providing care to the beneficiary. In 2022, revisions were made to Chapter 12 Section 30.6.18 of the Medicare Claims Processing Manual to coding and documentation for split/shared visits.

Definition of Split (or Shared) Visit – A split (or shared) visit is an evaluation and management (E/M) visit in the facility setting that is performed in part by both a physician and a nonphysician practitioner (NPP) who are in the same group, in accordance with applicable law and regulations such that the service could be billed by either the physician or NPP if furnished independently by only one of them. Payment is made to the practitioner who performs the substantive portion of the visit.

Facility setting means an institutional setting in which payment for services and supplies furnished incident to a physician or practitioner’s professional services is prohibited under our regulations.

As the CMS definition indicates, the ED physician and PA/NP must be part of the same group to report a split/shared visit.  As there are many varied circumstances under which ED physicians and PAs or NPs interact and the stipulation for “same group practice” may be open to interpretation, you are advised to seek legal counsel related to different group structures’ final instructions on billing when shared services arise. In addition, some non-Medicare payers still do not recognize PAs or NPs, so the service may have to be reported using the physician’s NPI.

The CMS definition indicates payment is made to the physician or NPP that performs the substantive portion of the visit; how does CMS define the substantive portion?

The CY 2024 Final Rule indicated that CMS would be adopting the CPT definition of substantive portion for 2024.

In consideration of the changes made by the CPT Editorial Panel, we are revising our definition of “substantive portion” of a split (or shared) visit to reflect the revisions to the CPT E/M guidelines. Specifically, for CY 2024, for purposes of Medicare billing for split (or shared) services, the definition of “substantive portion” means more than half of the total time spent by the physician and NPP performing the split (or shared) visit, or a substantive part of the medical decision-making as defined by CPT.

Page 476 CY 2024 Final Rule