Karen Posted Tue 13th of December, 2011 18:02:53 PM
If an APRN sees a patient & documents and MD comes and sees the patient at the end of the visit and documents that he saw the patient and comments on the Medical decision making would this be adequate to charge shared Split visit under the MD PIN # or does he need to document the Medical necessity of having to have gone in to see the patient as well?
SuperCoder Answered Wed 14th of December, 2011 21:19:06 PM
Rules for reporting inpatient split-shared
When reporting an inpatient split-shared visit, remember these rules:
The split-shared visit rules state that both the NPP and the physician must have a face-to-face encounter with the patient on the day the facility or practice reports the service. Both the physician and the NPP should document their participation of the visit in the medical record. The physician practice employs the NPP. Do not report a shared visit when a hospital facility or other entity employs the NPP. The physician cannot simply state “reviewed and agree” in the record without seeing the patient personally. CMS permits hospitals to report new and established patient encounters in the hospital setting as a split-shared visit.
In addition, the physician must perform and document at least some of the three key components of E/M services (i.e., the history, the exam, and the medical decision-making). Review the details of E/M services in your 2010 CPT® Manual.