Split or shared visits are integral to team-based care in primary care settings, involving both a physician and another Qualified Healthcare Professional (QHP) in delivering patient care during a single Evaluation and Management (E/M) service. For accurate medical decision making coding in primary care, understanding the nuances of these visits is crucial. When both a physician and a QHP contribute substantively to the encounter, either may report the service, provided they perform a substantive portion of the visit.
Time is a significant factor in determining the appropriate coding level for split or shared visits. The total time spent by both the physician and the QHP on the encounter date is combined. However, it’s essential to count only distinct time. If there’s overlapping time, such as when both professionals are jointly discussing the patient, only the time of one individual should be included. When selecting the code level based on time, the service should be reported by the professional who spent the majority of the total face-to-face or non-face-to-face time with the patient. This time-based approach is vital for accurate medical decision making coding, especially in primary care where time spent with patients is a key component of service.
It’s also important to remember that time spent on separately reported services cannot be included when calculating the total time for the E/M service level. For instance, if a procedure like a skin tag removal is performed during the same visit, the time for that procedure is billed separately and should not be counted towards the E/M service time. In such cases, documentation should clearly state what time was not included in the total visit time due to these separate services. For example, your notes might state: “Skin tag removal on the patient’s left arm took 10 minutes and is billed separately, not included in the total visit time.” This distinction is key for compliant medical decision making coding.
Finally, avoid using template or standard times in your documentation. Auditors often flag this as a potential issue. Do not, for example, routinely document that every Level 3 visit lasted exactly 20 minutes. Your documentation should accurately reflect the actual time spent on each patient encounter. Accurate and specific time documentation is paramount for proper medical decision making coding in primary care split or shared visits, ensuring compliance and appropriate reimbursement.
