EM Coding Alert

Make sure physicians understand documentation guidelines.

When you are considering coding an E/M service as split/shared, you must make sure that the providers include notes in the medical record confirming this fact. Additionally, the physician must write a link to the nonphysician practitioner’s (NPP’s) note.

Consider this case study from Cynthia A. Swanson RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb. In it, she gives a detailed description of a split/shared visit, along with suggestions for documenting the encounter:

It’s Tuesday at the local hospital. A PA rounds on an inpatient in the morning and assesses the patient for dehydration, nausea/vomiting and diabetes. The PA documents his assessment and the components of the E/M service he performed in the patient record. The PA then provides his signature to the encounter form to confirm its validity.

Later that Tuesday, the physician rounds on the patient, reviews the PA’s prior notes and performs her patient assessment. The physician documents the E/M components she provides in the patient record as well as links to the PA’s notes from earlier in the day.

The final hurdle: This visit has all the hallmarks of a split/shared visit. Put the final shine on the claim by ensuring that the physician’s documentation is thorough. It isn’t enough for the physician to sign off on the encounter form; she’ll need to provide more detail.

While the exact verbiage will differ depending on encounter specifics, Bucknam offers these examples of the types of physician documentation that could support a split/shared visit for the above case study. (It is important to remember that the claim must include evidence of the face-to-face time both providers spent with the patient.):

• “Seen and agree with above. I have examined this patient and my finding are … (Ex. Lungs clear, abdomen soft/non-tender, etc.)”. Followed by the physician’s legible signature/electronic signature.
• “Seen and agree with above. I provided face-to-face care along with ______; my physical findings are ...”. Followed by the physician’s legible signature/electronic signature.
• “Seen and agree with above. Based on my findings, ...”. Followed by the physician’s legible signature/electronic signature.

Conversely, Bucknam also offers these documentation examples that won’t cut it on your split/shared visit claims.:

• “Above noted. Proceed with discharge as planned.” Followed by the physician’s legible signature/electronic signature.
• “As above.” Followed by the physician’s legible signature/electronic signature.
• “Saw patient and orders written”. Followed by the physician’s legible signature/electronic signature.
• No comment at all by the physician or only a physician’s legible signature/electronic signature.

“The above documentation examples fail to establish a face-to-face encounter by the physician with the patient” and thus does not prove this was a split/shared service, Bucknam says.