The Clinician's Digest

Teaching & Shared Visit Billing

September 23, 2024 Volume 1, Issue 3

Guidance for Teaching & Shared Visits

“See one. Do one. Teach one.”

Healthcare is often provided in collaborative settings that require teamwork, incorporating many skill levels and practice roles.  Physicians, nurse practitioners, and physician assistants often care for patients together. Trainees are frequent team members, as medicine is grounded in active learning, with a long-standing tradition of apprenticeship-like structure and bedside teaching. 

Proper attribution for one’s role in a patient’s care is important to document, not only when oversight or supervision is necessary, but also to accurately reflect the amount and medical necessity of care provided.

This edition of The Clinician’s Digest focuses on documentation and coding for joint visit types with residents/fellows and advanced practice providers, based on the guidance of our compliance team.

Teaching physician documentation with residents & fellows

When overseeing residents & fellows, the attending physician is still personally responsible for the services provided.

Evaluation & Management (E/M) Services

A resident/fellow may provide and document provision of services when their teaching physician is physically present during critical or key service parts.

  • The medical record MUST demonstrate (via attestation):
  1. That the teaching physician performed the service or was physically present during the key or critical portions of the service provided by the resident/fellow AND
  2. The participation of the teaching physician in the management of the patient
  • When coding based on time, ONLY the time the attending was physically present with the patient may be selected for coding.
  • Do not add together resident & attending time.

Procedural (Minor) Services

For procedures taking five minutes or less to complete, e.g., simple suture, with relatively little decision making once the need for the operation is determined, the teaching surgeon must be present for the entire procedure in order to bill for the procedure. You must document your presence within your attestation.

Procedural (major) Services

To bill for surgical, high-risk, or other complex procedures, the teaching physician must be present during all critical and key portions of the procedure and be immediately available to furnish services during the entire procedure. You must document your presence within your attestation.

Don’t forget!

Add a –GC modifier to any services performed by a trainee in a teaching facility under the direction of a teaching physician.

Add an –FS modifier to split/shared E/M services.

Split / Shared Visits

Under certain conditions, a Physician and Advanced Practice Provider (APP) from the same group practice may each personally perform and document a medically necessary portion of a face-to-face and non face-to-face Evaluation and Management (E/M) encounter on the same date for a patient. The E/M service may be reported and billed under the Physician or APP’s provider number who performs and documents the substantive portion of the visit.

The following are key points for correctly conducting a shared visit:

  •  The E/M service should be reported & billed by the clinician who performs the substantive portion of the visit.
  • Recommended best practice is to use medical decision making (MDM) as the substantive portion.
  • Documentation needs to clearly reflect the MDM elements of the E/M services performed.
  • Face-to-face activities with the patient should be clear, i.e. performing a physical exam
  • For billing compliance, append an FS- modifier to the E/M service to identify the service split.

It is NOT appropriate to review, co-sign, & approve APP notes.

Essential Documentation Elements

The documentation should clearly demonstrate the shared visit, including:

  • Identification of both providers
  • Link the Physician & APP notes
  • Both providers have legible signatures
  • Clearly illustrate that both saw and performed E/M patient services

A separate document linking both notes is strongly recommended.

What services can be split?

  • New & Established Clinic Visits
  • Emergency Department
  • Hospital Observation
  • Hospital Inpatient/Discharge

What services cannot be split?

  • Consultations
  • Procedures
  • Critical Care Services
  • Intensive Care Services