Split or shared visits occur when a physician and another Qualified Healthcare Professional (QHP) collaborate to provide care for a patient during a single Evaluation and Management (E/M) service. In these team-based care scenarios, accurate coding is crucial for primary care physicians to ensure appropriate billing and compliance. This article outlines the key principles of proper coding for split or shared visits, focusing on time-based considerations and documentation best practices.
When conducting a split or shared visit, both the physician and the QHP contribute to the patient’s care. To determine the correct level of service for billing purposes, the time each professional personally spends with the patient on the date of the encounter is combined. It is essential to only count distinct time. If there are periods of overlap, such as when the physician and QHP are jointly meeting with the patient or discussing the case together, this time should only be counted once, attributed to a single individual.
The selection of the appropriate E/M code level in split or shared visits often relies on the total time spent on the date of the encounter. In cases where time is the determining factor, the service should be reported by the professional who devoted the majority of the total face-to-face or non-face-to-face time to performing the service. This ensures accurate representation of the primary care physician’s or QHP’s contribution to the patient’s care.
It’s also important to remember that time spent on separately reported procedures or services cannot be included when calculating the total time for the E/M service level. For instance, if a primary care visit includes a separately billed procedure like a skin tag removal, the time spent performing the removal should not be added to the total visit time for E/M coding purposes. In such cases, it is advisable to include a statement in the documentation that clarifies what time is included and excluded. For example, documentation might state, “The 16 minutes spent on skin tag removal from the patient’s left arm was billed separately and is not included in the total visit time.”
Finally, primary care physicians should avoid using standardized or template times in their documentation. Reliance on template times can raise red flags during audits. For example, consistently documenting every Level 3 encounter as precisely 20 minutes or routinely including 15 minutes for EHR documentation across all visits is not recommended. Documentation should accurately reflect the actual time spent on each individual patient encounter. This practice ensures transparency and compliance in coding for split or shared visits in primary care settings.
