Understanding the latest updates in billing for shared and split medical visits is crucial for healthcare providers aiming for accurate reimbursement and compliance. The recent revisions to the AMA’s CPT guidelines, effective from January 1, 2024, aim to clarify how providers can bill for evaluation and management (E/M) services when multiple practitioners are involved. These changes help streamline processes, prevent billing errors, and ensure providers are appropriately compensated for their contributions. Proper comprehension of these rules not only benefits practitioners but also enhances transparency and efficiency within healthcare billing systems.
Definition of Split or Shared Visits
A shared or split visit involves multiple healthcare providers contributing to a single patient encounter. The core concept centers around the “substantive portion” of the service, which determines which provider can bill for the visit. This substantive portion can be identified through two primary methods:
- Time-Based Method: The provider who spends over half of the total clinical time during the visit is considered the primary billing practitioner. This includes activities such as patient preparation, examinations, counseling, and documentation.
- Medical Decision Making (MDM): Alternatively, billing can be based on the complexity and significance of the medical decision-making involved. If a provider performs a critical part of the MDM—such as developing a management plan—they may qualify as the billing provider, even if they did not spend the majority of the visit time.
These updates aim to eliminate confusion by clearly defining which provider’s activities are billable, based on documented evidence of substantive work performed. For further insights, healthcare professionals can explore decoding the acronym what does app stand for in healthcare, which highlights the importance of understanding key healthcare terminologies.
Time-Based Billing Components
Activities contributing to the total clinical time include a variety of tasks performed before, during, and after the patient encounter. Accurate documentation of these activities ensures proper billing and compliance:
- Reviewing prior tests and preparing for the visit
- Gathering and analyzing patient history
- Conducting physical examinations and evaluations
- Counseling patients and their families
- Ordering medications, laboratory tests, or diagnostic procedures
- Communicating with other health professionals regarding the patient’s care (when not billed separately)
- Documenting clinical findings and results
- Interpreting diagnostic results independently and explaining them to the patient
- Coordinating ongoing care and follow-up arrangements
It is essential to distinguish these activities from non-billable time, such as:
- Performing services billed separately
- Traveling between locations
- Conducting general teaching unrelated to specific patient management
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Medical Decision Making (MDM) and Billing
In cases where the time spent does not clearly establish the billing provider, MDM plays a pivotal role. The CPT guidelines specify that:
- The provider must create or approve the patient’s management plan.
- The provider assumes responsibility for this plan, including any associated risks.
This means that a provider can bill for a shared visit based on the quality and complexity of their decision-making, even if they did not spend more than half of the visit time. For example, developing a care plan or making significant adjustments qualifies as a substantive contribution. Notably, providers are not required to perform certain actions, such as ordering tests or reviewing external documents, to bill based on MDM. However, they must personally interpret external results or discussions if these influence the billing level.
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Practical Case Study
Consider a patient with chronic obstructive pulmonary disease (COPD) admitted to the hospital. The nurse practitioner (NP) conducts an initial assessment, reviews medical history, and makes preliminary treatment decisions. Later, the pulmonologist reviews the NP’s notes, examines the patient, and finalizes the treatment plan. Since the pulmonologist performs a substantive part of the MDM—adjusting and approving the care—the visit can be billed under their name and National Provider Identifier (NPI). This scenario illustrates how understanding the definitions of substantive work ensures proper billing, which benefits both providers and patients.
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Effective billing for split or shared services depends on clear documentation, understanding of the substantive work performed, and adherence to updated guidelines. By recognizing the roles of time-based activities and medical decision making, healthcare providers can ensure accurate reimbursement and compliance with the latest CPT standards. This clarity ultimately promotes a more transparent, efficient healthcare system that benefits practitioners and patients alike.