Medical Billing Guidelines for Shared Visits

If both the physician and the non-physician practitioners see the patient the same day, they both provide a face-to-face service. We can combine their services and bill it under either the physician or under the non-physician practitioner. Well, if you’ve got that option, why not bill it under the physician for the high level of reimbursement? But there does have to be a face-to-face encounter by both the non-physician practitioner and the physician to bill it as a shared visit. Read this E & M coding expert article for more.

Now, shared visits have been around for a few years now but there's still a little confusion over the documentation. Terrence Kay from CMS said, “Any face-to-face portion of an E/M service, in whole or in part. So it can be history, it can be exam, it can be decision-making. A social salutation alone does not constitute a face-to-face portion.” So, if there’s – it's got to be a medically necessary physician involvement just like everything in the Medicare program that you have to have medical necessities to support that.

And so, it's not just; the patient (that they're seeing). It really is some part of that visit. Now, there's a difference here between what the regulation says and what a consultant is. It is much better if the face-to-face portion is exam. And it's because that’s the only one of the key components that has to be face-to-face. Think about it. The history can be obtained by reviewing somebody else’s history. The medical decision-making can be done by reviewing the medical decision-making that’s already been completed or making your decision based on test results and other information.

So history and decision-making don't have to be face-to-face. But the exam does have to be face-to-face as per medical billing rules. Now, we can't say that Medicare absolutely requires it to be the exam, but part of what we look at is how sensible is it? It's going to be much easier to justify the fact that the exam was face-to-face than necessarily the other two components. That would be best practice’s recommendation that the part of the face-to-face that the physician does is the exam.

So, what kind of evaluation and management documentation guidelines and examples are we going to see for a shared visit? So we’re either going to see a separate visit by the physician detailing some part of that E/M service. And ideally, you want to see that physician linked to that non-physician practitioner’s note. Remember, we’re talking about hospital charts here. We’re not talking about office charts, we’re talking about a hospital place of service.

So we’re talking about a hospital chart that may have progress notes from three or four or five different physicians seeing that patient. How  are you going to know to go look for a note by the non-physician practitioner if the physician does not link it or does not reference it? So ideally, you  want to see that. You want to see previous note by my nurse practitioner or something that links those two notes that same day.

Medical Billing Training Tip: The physician note doesn’t have to come after the non-physician practitioner’s note. It doesn’t really matter as long as they both see the patient face-to-face that same day, but you have to have some way of knowing to go look for that note. We’re still dealing with primarily handwritten notes in the facility setting and that is where the non-physician practitioner has made her notations or his notations and then the physician comes behind and adds to it. And in this case, the handwriting difference is going to be the key.

Now, most hospitals  are still using handwritten notes at this point and few that are using electronic record in the hospital. And at that point, we’re going to again, have to have some way to link those two notes.

But right now, where we’re still using handwritten notes, there are a lot of cases where the physician makes notations within that nurse practitioner – that PA’s note or below it or something that let's you know that you participated in that visit.  So just writing, “Seen and agree” next to that non-physician practitioner’s note or is a separate note, that’s not enough to support that that physician provided a face-to-face service.

Not shared visits: They're not shared visits because Medicare said they're not shared visits. First of all, procedures can't be shared as per medical billing rules. And procedure is done by one person or the other, not by two people. Consultations are not shared because what Medicare has said is that an opinion should be requested over one person. This is probably the most troublesome aspect of shared billing because this is how they a lot of providers use their nurse practitioner and their PA to help them with their consultations in the hospital setting, but a consultation cannot be shared.

Welcome to Medicare visit is not a shared visit because Congress didn’t say it was. When Congress wrote the law establishing the welcome to Medicare benefit, they did not say that it could be a shared visit. And critical care cannot be shared.

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