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Coding for Evaluation and Management Services

A split or shared visit is when a physician and other QHP act as a team in providing care for the patient, working together during a single E/M service. If the physician or other QHP performs a substantive portion of the encounter, the physician or other QHP may report the service.

When providing a split or shared visit, the time personally spent by the physician and QHP on the date of the encounter is summed to select the appropriate level of service. However, only distinct time should be counted. When there is overlapping time (e.g., jointly meeting with or discussing the patient) only count the time of one individual. When code selection is based on total time on the date of the encounter, the split or shared service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service.

Additionally, and as noted above, time spent on activities reported separately cannot be included in the total time used to select the level of E/M service. In those instances, you should include a statement specifying the total time does not include time spent on such services. For example, for an encounter that included the removal of a skin tag, you could include a statement such as, “Removal of the skin tag from the patient’s right armpit took 16 minutes. It was not included in the total time of the visit and was billed separately.”

Finally, do not use standard or template times for your documentation because that can be a red flag for auditors. For example, do not document that each Level 3 encounter lasted exactly 20 minutes or that each encounter included 15 minutes related to documenting in the EHR. Your documentation should reflect the actual time spent for each encounter.

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