Revenue Cycle Insider

Question: Our hospitalist and nurse practitioner (NP) both saw the same patient on the same date. The NP completed the history, exam, and part of the medical decision making (MDM), while the hospitalist later reviewed the patient, updated the treatment plan, and documented additional decision making. We want to bill the encounter as a split/shared evaluation and management (E/M) service, but we’re unsure which provider should report the visit. How do we determine who performed the substantial portion of the services, and what documentation is required to support the claim?

Florida Subscriber

Answer: This encounter may qualify as a split/shared E/M service if both the hospitalist and the NP are in the same group (part of the same practice), and each performed part of the service on the same date. The provider who reports the visit is the one who performed the substantial portion of the encounter. Under current CPT^® guidelines, this portion can be determined based on either time or MDM.

A summary of the CPT^® guidelines regarding split/shared E/M services tells us that when code selection is based on time, the billing provider must perform the substantive portion of the visit, defined as spending more than half of the total face-to-face and non-face-to-face time attributable to the encounter.

If code selection is based on MDM, the billing provider must make or approve the management plan, assume responsibility for that plan and its associated risks, and perform enough MDM work to support code selection. When data review contributes to MDM, some activities may be performed by either provider, but any independent interpretation of tests or discussions used to support the reported MDM level must be personally performed by the billing provider.

To support a split/shared service, both providers should separately document their contributions to the encounter, including their individual work and any time spent if time is being used to determine the billing provider. The record should clearly identify which provider performed the substantial portion of the service and is reporting the E/M visit.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC