The revisions give emergency physicians and APPs clearer shared visit documentation standards, helping align the work performed with provider assignment and accurate claim filing.
Emergency physicians and advanced practice providers (APPs) often work together during a single evaluation and management service. Under the shared visit rule, their combined care can support one E/M service. However, documentation must identify which practitioner performed the substantive portion of the visit.
To report the service under the physician, the physician must perform and document the substantive portion. The service then qualifies for payment at 100% of the physician fee schedule. Notably, incomplete or unclear documentation can separate the clinical work from the provider assignment that supports accurate claim filing.
Physicians can establish the substantive portion in one of two ways. First, the physician can provide more than half of the shared visit’s total time. Second, the physician can perform the substantive portion of the medical decision-making (MDM). History and examination no longer determine the substantive portion.
For the MDM path, the physician must make or approve the management plan for the problems addressed. The physician must also accept responsibility for that plan, including its inherent risk. This work represents two of the three elements that guide E/M code-level selection based on MDM.
The combined physician and APP documentation should accurately reflect the patient’s condition, the services delivered in the emergency department, and the E/M code assigned. The physician does not have to rewrite the entire MDM. Instead, the physician may review and approve the APP’s documentation and attest to performing the substantive portion of the MDM.
Alternatively, the physician may independently document the MDM elements personally performed during the encounter, such as the plan of care, medications prescribed, interpretations, or discharge instructions. When independent documentation regarding the shared visit is present, an additional attestation is not required.
The physician may rely on information in the APP’s note when making or approving the management plan. However, if the reported code level depends on an independent interpretation of a test or a discussion with an external physician, the emergency physician must personally perform and document that interpretation or discussion.
When time establishes the substantive portion, the chart must clearly state that the physician personally provided more than half of the total time. At least one practitioner in the shared visit must have face-to-face contact with the patient. That practitioner does not have to be the one who performs the substantive portion and reports the visit.
Zotec’s intelligent coding, Zotec Documentation Improvement (ZDI), and clinician education help identify documentation gaps while the note is still actionable. Provider-assignment controls then connect the supported billing practitioner to direct-to-carrier claim filing. This helps the correct supervising-provider data follow the claim.
By keeping clinical documentation, coding review, provider assignment, and claim submission aligned, Zotec helps emergency medicine teams support accurate reporting while allowing physicians and APPs to remain focused on patient care.
