PYA Principal Valerie Rock contributed to the article, “Documentation of ‘Substantive Portion’ for CMS, CPT May Not Align, Creating Audit Risk,” published in the Dec. 11, 2023, issue of the Report on Medicare Compliance. The national publication is produced by the Health Care Compliance Association (HCCA) to provide updates on compliance strategies specifically pertaining to Medicare.
The article, written by Nina Youngstrom, brings to light the apparent conflicting documentation requirements related to the American Medical Association’s Current Procedural Terminology (CPT©) definition of “substantive portion” for a split/shared evaluation and management (E/M) visit and related requirements from the Centers for Medicare and Medicaid Services (CMS).
Rock explains the CMS regulation “could be interpreted as requiring the physician to document the [medical decision-making] independently in support of the E/M code,” which could cause problems for physicians who minimally document split/shared visits.
As CMS has revised its guidance regarding split/shared visits since 2022, it seems to have required more oversight and documentation from the physician, which is at odds with the new CPT definition. This conflict is causing variances in the interpretations of the guidance and could result in a non-compliance audit finding.
The article states,
“CMS is saying if you’re going to be the billing provider, you need to document what you actually reviewed specifically and what plan you’re approving so you can support medical decision making,” Rock said. “It’s possible CMS meant that the physician only has to summarize or refer to the MDM already documented by the [nonphysician practitioner], along the lines of CPT, but my fear is that auditors will translate that the physician has to document medical decision-making independently in support of the code reported.” She advises watching for updates to the Medicare manual and Medicare administrative contractor (MAC) guidance to get a better sense of expectations.
Read the full article about substantive portion documentation on HCCA’s online platform, COSMOS, or access a PDF of the article.
If you have questions about documentation for split/shared visits, coding review, or any other matter related to compliance or strategy and transactions, contact our executive contacts at (800) 270-9629 or the e-mails below.
