Awareness : OBC Tips

Split/Shared Visits Documentation Guidelines

These are the key elements that must be met in order to bill a split/shared visit:

  • A shared/split visit can only be utilized if the NPP and physician are from the same group practice, including the same specialty.
  • The NPP and physician must both perform and document their face-to-face encounter with the patient.
  • The portion of the E/M service performed and documented by both the NPP and physician must be substantive, which includes part or all of the history, exam or medical decision making.
  • Not applicable to Consultations, Procedures or Critical Care Services.

    In all cases, documentation must substantiate the medical necessity of the shared/split visit; support the level of E/M code submitted, and the medical record should contain enough detail to allow a reviewer to:

    • identify both providers
    • link the physician notes to those of the NPP
    • include legible signatures from both providers
    • confirm that the physician and the NPP both saw the patient face-to-face
    • include legible/electronic signature

      Following are examples of physician documentation that would meet these criteria:

      “I have personally performed a face to face diagnostic evaluation on this patient.  I have reviewed and agree with the care plan.  History and Exam by me shows:  abdomen was tender to touch, no rebound.  Labs /CT scan negative.  IM Toradol given for pain. Pt discharged home.” Signed by treating physician

      The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and non-facility clinic visits, and prolonged visits associated with these E/M visit codes). The split/shared E/M policy does not apply to consultations, critical care services or procedures.  These must be entirely performed by the NPP or the physician and billed by the provider furnishing the entire service.