Part B Insider - 2016 Issue 9
Case Study: Use This Advice to Check Your Shared/Split Visit Claims
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Article Overview
This article explains documentation-focused guidance for split/shared E/M visits in an inpatient setting. It is aimed at coders, auditors, compliance staff, and clinicians who need to understand what record elements are expected when both a physician and an NPP participate in the encounter. The discussion centers on how the physician note should relate to the NPP documentation, what kinds of record support are considered more complete, and what types of entries may be insufficient.
Why This Topic Matters
Split/shared visit claims are highly documentation-sensitive, and incomplete records can create compliance risk or claim denial exposure. This article helps readers recognize the kinds of provider documentation and record linkage that affect whether a service is supportable.
What You Will Learn
- How split/shared E/M visit documentation is evaluated in a real-world case study
- What types of physician note elements help support a shared encounter record
- What kinds of documentation patterns may be considered insufficient for support
- Why record linkage between the physician and NPP notes matters
- How face-to-face participation by both providers is reflected in the chart
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Physicians
- Physician assistants
- Nurse practitioners
- Revenue cycle staff
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