I have a question about the new 2023 requirements for an E/M visit in an office that is classified as a hospital outpatient department. I have a physician that does a shared visit with his NP. He doesn't document time spent, or if he does, he just documents total time, not individual time by both of them. In his note, he documents " The plan, assessment and decision was done by me (MD NAME). (NP Name), contributed to the history and exam". Is that sufficient to show that he performed the substantive portion of the visit, or by new guidelines, does he and the NP both need to document how much time they each spent?
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki Split/Shared visit
- Thread starter Jslibby02@gmail.com
- Start date
jkyles
True Blue
- Messages
- 933
- Best answers
- 1
Hi there,
Under Medicare's rules for billing the substantive portion is based on performance of one component (history, exam or MDM) or time. It appears that your physician has documented that he performed MDM.
Under CPT guidelines for coding a split/shared visit you can only use time, but if the doctor only document the time they spent together and face-to-face with the patient the code may not reflect all of their work.
Under Medicare's rules for billing the substantive portion is based on performance of one component (history, exam or MDM) or time. It appears that your physician has documented that he performed MDM.
Under CPT guidelines for coding a split/shared visit you can only use time, but if the doctor only document the time they spent together and face-to-face with the patient the code may not reflect all of their work.