In the realm of primary care, accurate medical coding is paramount for proper reimbursement and compliance. Navigating the complexities of Evaluation and Management (E/M) coding, especially for services involving multiple healthcare professionals, requires a thorough understanding of specific guidelines. This article delves into the nuances of split or shared visits within Primary Care Coding Guidelines, clarifying how these team-based encounters should be documented and coded.
A split or shared visit occurs when both a physician and another qualified healthcare professional (QHP), such as a nurse practitioner or physician assistant, collaborate in providing care to a patient during a single E/M service. In these scenarios, both professionals contribute to the patient’s care within the same encounter. To appropriately report these services, primary care coding guidelines stipulate that the physician or QHP who performs a substantive portion of the encounter is the one who should report the service. This emphasizes the importance of clearly defining and documenting each professional’s role in the visit.
Time plays a crucial role in determining the appropriate E/M code level for split or shared visits when coding based on time. Primary care coding guidelines specify that when selecting the level of service based on time, the total time personally spent by both the physician and the QHP on the date of the encounter can be combined. However, it is essential to only count distinct time. If there is any overlapping time, such as when both professionals are jointly discussing the patient or meeting with them simultaneously, this time should only be counted once, attributed to a single individual. Furthermore, when the code selection hinges on the total time spent on the date of the encounter, the primary care coding guidelines dictate that the split or shared service must be reported by the professional who dedicated the majority of the face-to-face or non-face-to-face time to performing the service.
It’s also vital to remember that time spent on activities that are reported separately cannot be included when calculating the total time for selecting the E/M service level. Primary care coding guidelines are clear on this point. In cases where separately reportable services are provided during the same encounter, documentation should explicitly state that the time spent on these services is excluded from the total visit time. For instance, if a minor procedure like a skin tag removal is performed during a primary care visit, the time spent on this procedure, which is billed separately, should not be included in the total time used to determine the E/M code level. Documenting a statement like, “Time spent on skin tag removal (15 minutes) is not included in the total visit time and is billed separately,” ensures compliance and clarity.
Finally, primary care coding guidelines strongly advise against using standardized or template times in documentation. Employing such practices can raise red flags during audits. For example, consistently documenting every Level 3 encounter as exactly 20 minutes or uniformly allocating 15 minutes to EHR documentation across all encounters is not acceptable. Documentation must accurately reflect the actual time spent on each individual patient encounter. This emphasis on precise and individualized time documentation is a cornerstone of compliant primary care coding practices for split or shared visits.
