Q I read with great interest your recent article on shared visits. Our practice has a hospitalist component that relies on midlevels. Your sourcing of the Medicare transmittal helped a lot to tell us what not to do, but of course far be it from Medicare to tell us what to do.

As soon as I relayed that portion to our hospitalists, I had two of them in my office scared to death, saying, “What are we supposed to do? We have used the term ‘incident-to’ to bill for hospitalized patients seen by the midlevel. Today we received clarification suggesting that we (doctors) should document a portion of the visit to ensure that we meet shared/collaborative visit requirements.”

Your article (like the transmittal) didn’t really address what to do or document. Some of the specialty docs have started to ask me as well. Can you clarify?

A You have put your finger on it. Medicare does not say how much each provider needs to document to qualify as shared. It says: “A split/shared visit is a medically necessary encounter with a patient, where the physician and a qualified NPP each personally perform a substantive portion of an E&M visit face-to-face with the same patient on the same date of service.”

We have no way to quantify “substantive portion.” It’s the same with other Medicare language that refers to some face-to-face portion. We don’t know what is enough.

That said, since the key word is shared, and the tendency is to let the extender do most of the work while the MD often essentially does the “review and agree” bit, my suggestion is that the sharing look more shared than like incident-to.

The question boils down to how much is enough physician documentation/participation. Medicare doesn’t exactly say, but I doubt they’d have a problem telling you what they didn’t like.

So, make sure the physician’s face-to-face portion is documented (by the MD), and that it goes beyond a macro, or stock comment, and supports physician presence — say something subjective about the patient’s condition or salient findings.

Further or additional workup

Q I have a question about the first of the three decision-making tables for E&M: the number of diagnostic and management options. One entry says “New problem (to the patient), no further workup planned” and the next one says “New problem (to the patient), additional workup planned.”

I’ve always read that as meaning if I do any workup, labs, imaging, etc., I get the second one. I was just told that’s not true. Which is it?

A You are in the minority if you read it that way. In the first indicator, “New problem (to the patient), no further workup planned,” the language “further workup planned” should be a hint. The first issue is the word “further.” What do they mean by that? No further than what? It means no further than the workup you’ve already done during that encounter. And that would include labs and imaging.

And then there’s that word “planned.” That would take the work outside the context of the current visit, even if it’s workup that will be done on admission, for example.

The second indicator, “New problem (to the patient), additional workup planned,” also has some hints in it. The word “additional” again means that workup has been done in the current visit — and that more will be needed to get to the bottom of the patient’s problems. More is planned — later.

Don’t believe me? Here are some Medicare carrier opinions on the subject:

A Medicare carrier “would like to clarify the review requirements in the first grid entitled ‘new problem to examiner; additional workup planned.’

“Additional workup is defined as workup that is planned beyond the time of the present encounter. For example, a physician sees a patient in the office and determines additional information is needed to complete the medical decision or treatment plan. The physician sends the patient for further testing, such as diagnostic studies, clinical labs, etc., but the patient does not return to see the physician on the same day. In this scenario, the diagnostic studies constitute additional workup planned.