Wiki 2022 IP Hospital E/M Final Rule Shared/Split

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BonnieJ123

Networker
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84
Location
Wichita, KS
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I have listened repeatedly to webinars and researched diligently. I understand the substanitve portion of the visit (hx, exam or mdm). Time will not be used in our group so just focusing on the three key components. What I need is a good example of documentation from the physician billing as the substantive portion practitioner. I am struggling also with sub days IP and if mdm is used as the substantive portion and does not change day to day- what example can you show me of your documentation to bill under the physician NPI#. I have read that when both the practitioners document the substantive portion that the level only goes off the billing provider's documentation. Please help give some insight on documentation for the billing provider. I have a grasp on the level. Thanks
 
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Sorry, I do not have any insight into your question. I also would appreciate some insight in to the sub day for IP documentation and the MDM (not changing much).
 
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I would love to provide you with an example to bill under the physician, but I don't have one. My MDs tend to write an additional line or two and sign off. My IP billing is done under the NPPs unless they were seen only by the MD.
If you are using MDM as the substantive, then you may only code to the level of documentation by the MD of number of diagnoses, data and risk. The level of history or exam can then be by either provider.
You may wind up with more 99231 than anything else depending on your MD's documentation.
Example: 1 established problem, worsening (limited); order 3 labs, 1 xray (limited); adjust medication dose (moderate). Your MDM is low.
Your NPP may have performed a detailed history and detailed exam, but if you want to bill under the MD, since the MDM is low, you have 99231. If the physician even examined 2 organ systems, you may be better off deciding exam is your substantive since you have an expanded problem focused exam for 99232.
REMEMBER: 2023 is going to be time only. You should start getting your providers in the habit of documenting time.
 
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