In the May 13 issue of the Report on Medicare Compliance, Principal Valerie Rock is the featured expert on the new Medicare transmittal (12604) related to substantive portion and physician documentation for the continuously evolving split (or shared) evaluation and management (E/M) guidelines. The national publication is produced by the Health Care Compliance Association (HCCA) to provide updates on compliance strategies specifically pertaining to Medicare.
In the article, “Transmittal on Split/Shared Points to CPT, Says Nothing on Documentation,” written by Nina Youngstrom, Rock provides insight and clarity into confusion regarding split/shared E/M service documentation. In its recent transmittal, the Centers for Medicare & Medicaid Services defines “substantive portion”—an essential aspect of documentation—using the definition provided in the 2024 update of the Current Procedural Terminology (CPT©) manual but has not provided guidance on how to document it, she explains in the article.
Rock describes the audit risks physicians assume by not sufficiently documenting their portion. “Simply document the interaction, whether with or without the patient, any changes to the [management] plan and agreement with the management plan otherwise,” she says.
Read the full article about split/shared visit documentation on HCCA’s online platform, COSMOS, or access a PDF of the article.
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