Split or shared visits in Evaluation and Management (E/M) coding occur when a physician and another qualified healthcare professional (QHP) collaboratively deliver care to a patient during a single encounter. In this team-based approach, if either the physician or the QHP performs a substantive portion of the encounter, that professional is permitted to report the E/M service. This collaborative model is particularly relevant in primary care settings, where coordinated care teams are increasingly common.
It’s also critical to remember that time spent on activities that are reported separately should not be included when calculating the total time for the E/M service level. In such cases, your documentation should clearly state that the total visit time excludes time spent on these separate services. For instance, if a procedure like a skin tag removal is performed during the encounter, and it’s billed separately, your documentation could state: “Skin tag removal from the patient’s left arm took 12 minutes and is billed separately, therefore this time is not included in the total visit time.”
Finally, avoid using standard or template times in your documentation. Auditors often flag templated times as potentially inaccurate. For example, stating that every Level 3 visit lasted precisely 20 minutes, or that every encounter included a standard 15 minutes for EHR documentation, raises suspicion. Your documentation should genuinely reflect the actual time spent on each individual patient encounter to ensure compliant and accurate e&m coding primary care practices.
