Date

Attn: {MAC Medical Director Name}

RE: Review and Verify for Split/Shared Visits

Health Plan ID Number:	Group Number:
Insured/Plan Member:	Patient Name:
Claim Number:	Claim Date:

To Whom It May Concern:

{Insert org name here}, is deeply concerned about {Ins. Co's name} policy regarding split and/or shared services provided in the emergency department. We are asking for a uniform implementation of the below CMS rules and for certain attestations to be acknowledged as acceptable.

Page 476 of the 2024 Final Rule specifies, "In consideration of the changes made by the CPT Editorial Panel, we are revising our definition of “substantive portion” of a split (or shared) visit to reflect the revisions to the CPT E/M guidelines. Specifically, for CY 2024, for purposes of Medicare billing for split (or shared) services, the definition of “substantive portion” means more than half of the total time spent by the physician and NPP performing the split (or shared) visit, or a substantive part of the medical decision-making as defined by CPT.”

The primary documentation concern is that the medical record is clinically appropriate and accurately reflects the patient’s condition and services rendered in the ED; the combined documentation from the ED physician and PA/NP should support the E/M code assigned.

CMS policy stipulates that the documentation in the medical record must identify the individual practitioners who performed the visit. The practitioners who performed the substantive portion will bill for the visit and must sign and date the medical record.

In cases where the encounter is split/shared between the ED physician and the PA/NP, it is necessary for at least one of the practitioners to have face-to-face contact with the patient. However, it does not necessarily have to be the practitioner who performs the substantive portion of the visit and bills for it.

CPT guidelines do not explicitly outline specific documentation requirements; however, they do specify that the physician/QHP who developed or approved the patient's management plan and assumes responsibility for its implementation, along with its inherent risks, should be considered as having performed the substantive part of the MDM. Therefore, the ED physician's documentation should indicate their approval of the management plan and acceptance of responsibility for the patient's treatment.

In accordance with this existing principle, it is not required for the ED physician to document the MDM. Instead, they may review and approve the PA/NP documentation and attest to their performance of the substantive portion of the MDM. For instance, the physician may state: "I personally made/approved the management plan for this patient and take responsibility for the patient management."

{Org name} appreciates your prompt attention to this very important manner. In the interim, if you have any questions, or would like additional information, please contact {your contact person} at {phone number}.

Sincerely,

[Physician name]