Split/shared visits continue to be a frequent source of audit findings—not because the services weren’t appropriately provided, but because the documentation doesn’t clearly identify who performed the substantive portion of the visit.

The Documentation Requirement

CMS requires documentation to support the identification of the practitioner who performed the substantive portion of the encounter.

When billing a split/shared service:

• If billing is based on time, the billing provider must document performing more than 50% of the total visit time.
• If billing is based on medical decision-making (MDM), the documentation should clearly support that the billing provider performed the substantive portion of the medical decision-making.

Without this information, auditors may question whether the billed provider was eligible to report the service.

A Common Audit Trend

One recurring issue our auditors continue to identify is documentation that reflects both practitioners participated in the encounter, but never specifies who performed the substantive portion. In other cases, the note fails to indicate whether the service was billed on a time basis or on an MDM basis, making it difficult to validate the claim.

These omissions create unnecessary compliance risk—even when the care itself was appropriate.

🔍 Audit Takeaway

Split/shared services require more than documenting who saw the patient. The medical record should clearly identify who performed the substantive portion of the encounter and support whether billing is based on time or medical decision making. These are small documentation details that can make a significant difference during an audit.

Each Auditor Insight is inspired by trends our auditing team is seeing in practice or by industry developments that have meaningful implications for coding, documentation, and compliance. Our goal is to help organizations stay informed, reduce risk, and code with confidence.