Is your electronic health record (EHR) system able to track the substantive portion of a split/shared evaluation and management (E&M) inpatient visit based on time? If not, you need to ask your EHR vendor how—and when—they plan to help.
The implementation of the Centers for Medicare & Medicaid Services’ (CMS’s) proposed definition of the “substantive portion” for split/shared E&M inpatient visits will require action by hospitals and health systems and EHR vendors in documentation and compliance.
As indicated in our July 14 blog post, upon implementation of this billing policy change, the substantive portion of a split/shared inpatient E&M visit will be determined based on time rather than medical decision-making. To determine which provider is eligible to bill for the visit, the documentation must clearly demonstrate time elements related to the visit, such as:
- Preparing to see the patient.
- Obtaining and/or reviewing medical history.
- Performing an exam.
- Providing counseling or education.
- Ordering medication or tests.
- Coordinating care.
- Interpreting and communicating test results.
- Documenting clinical information in the medical record.
Not only will organizations be required to include a split/shared modifier (modifier FS) on the claim, but the individual who provides the substantive portion of the visit based on time must attest to such and sign and date the medical record.
How to Prepare
In preparation for the implementation of this billing policy change, currently slated for January 1, 2025, ECG recommends that you collaborate with your EHR vendor to determine whether system upgrades will be issued to ensure compliance with the new requirements. The system upgrades should allow you to track time by provider type for various elements of the visit.
Unfortunately, EHR vendors have provided little, if any, guidance to their hospital and health system clients. But just because they’re taking a wait-and-see approach doesn’t mean that you should. While you’re waiting for EHR vendors to release system upgrades to aid in compliance, ECG recommends that you work with your operational teams now to establish a process for tracking time and a method for communicating encounter changes to care teams and coders.
Regardless of the proposed delay to the split/shared E&M inpatient visit billing policy, performing these action items now will ensure that your organization is prepared for the change long before the implementation.
Edited by: Matt Maslin
Published August 14, 2023
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