Hi there, this doesn't show that the physician's MDM exceeds the NP's.
In your example, it isn't even clear if the attending physician actually saw the patient. It says they reviewed the chart and agree.
I agree, but I'm looking at the CPT manual E/M guidelines where it says the physician has to make "or approve" the plan "for the number and complexity of problems addressed" and takes responsibility for the plan with its inherent risk of complications etc. It says in doing so, the physician has performed 2 of the 3 elements used in the selection of the code level. I'm not sure how to determine that he approved the plan "for the number and complexity of problems addressed" - in other words, what does the physician's portion of the note have to include to show he meets the requirements?
When establishing the physician's ability to bill for a split or shared visit under their name/number based on TIME, then yes, the physician's time must exceed that of the NPP.
To bill under the physician based on the physician's MDM work, though, the physician is not required to have performed the majority of the MDM in comparison to the NPP. Instead, the physician is simply required to perform enough MDM to select a level based on MDM, which CPT calls "a substantive potion of the MDM" (not "THE" substantive portion of the MDM). When the physician documents his/her MDM work, CPT says the physician can EITHER "make" or "approve" the plan of the NPP. CPT says that by approving the NPP's plan (which itself is based on the problems identified in the assessment), the physician "has performed two of the three elements used in the selection of the code level based on MDM." Again, nowhere in the guidelines does it say that the physician needs to do MORE MDM than the NPP.
Now what does physician documentation expressing "approval" of another person's MDM look like? Well, we usually refer to that as an attestation. Yes, a physician attestation was explicitly prohibited for many years for split/shared services. But we can't allow that to prevent us from accepting the clear verbiage in the NEW CPT split/shared section stating the physician may either "make" or "APPROVE" the NPP's MDM. To be sure, you can see that some MACs are apparently uncomfortable with this specific CPT manual verbiage/allowance. They don't mention that the physician is allowed to "approve" the NPP's documented MDM on their websites, and instead either imply or explicitly require physicians to still document their own MDM in detail—as was required prior to this new language—even if it is identical to and in agreement with the NPP's assessment/plan. Some folks just have a hard time adapting to change quickly.
Also, even prior to the final version of the split/shared rules (CY 2024), CMS made it clear that only one of the two (physician vs. NPP) needs to see the patient face-to-face, and it doesn't need to be the billing practitioner. There is also no requirement in the CPT manual that the physician needs to see the patient face-to-face in order to "make" or "approve" of the NPP's MDM and bill the service under his/her name as a split or shared visit. That's an old CMS requirement from a few years back.
Because physicians weren't allowed to use an attestation to document their involvement in a split/shared visit for many years, and because for many years the physician WAS required to see the patient, these now-outdated rules/restrictions may actually seem more "correct" in people's minds for several years to come. This is understandable. But the current split/shared rules as outlined in the CPT manual, and which CMS has agreed to follow, put us in a different world. Read the CPT manual language as written, without being influenced by the way things were for so long, and in time these new rules/allowances will seem just as correct as the old ones. Thankfully, I do see certain MACs coming around, likely after internal discussions and a closer review of the new rules/allowances as expresed in the CPT manual.
