With the new 2022 Shared visit changes, modifier FS is to be reported on the E/M code.

One of the more difficult challenges in shared visit documentation is determining which provider has completed the substantive portion of the service. Even though the guidelines are clear on who gets the credit, when we review documentation from the coding perspective it is sometimes a bit muddy and difficult to determine who performed the service.  The challenge unfolds when we have the midlevel doing the substantive portion of the visit and the provider then also documents another substantive portion in their attestation.

What does substantive mean?

• Performing and documentation of the history;
• Or performance and documentation of the physical exam;
• Or performance and documentation of the medical decision making;
• Or spending more than half the total time of the encounter.

Educating providers on the documentation requirements is the key to appropriate billing.  Template changes, query processes, and/or policies and procedures might also help mitigate any issues with determining appropriate billing. 

At LexiCode, we have provided our team with in-depth education around shared visit documentation and requirements and work with the client to determine appropriateness when the documentation is not clear. 

The complete policy and final rule is available - CY 2022 PFS final rule.

Tricia Jolin, RHIA, CCS-P, CPC, CIRCC