Mastering CMS Split Shared Documentation Guidelines
Our AI medical scribe helps you maintain clear, compliant records that adhere to CMS split shared documentation guidelines. Generate structured notes that reflect the combined efforts of your care team.
HIPAA
Compliant
Documentation Tools for Shared Care
Features built to support the complexity of split/shared billing requirements.
Substantive Portion Tracking
Our AI drafts notes that clearly delineate the clinical work performed, helping you document the substantive portion required by CMS.
Transcript-Backed Citations
Review your encounter audio transcript alongside the generated note to verify that all clinical contributions are accurately captured.
EHR-Ready Note Styles
Generate notes in SOAP or H&P formats that are ready for clinician review and seamless integration into your EHR system.
How to Document Shared Encounters
Follow these steps to ensure your documentation meets regulatory standards.
Record the Encounter
Use the app during the patient visit to capture the full dialogue between the clinician, the patient, and any other participating providers.
Review Generated Drafts
Examine the AI-drafted note against the transcript-backed source context to ensure the documentation accurately reflects the shared care provided.
Finalize and Export
Edit the note as needed for clinical precision, then copy and paste the final, compliant documentation directly into your EHR.
Understanding Split/Shared Documentation
CMS split/shared documentation guidelines require that the billing practitioner perform a substantive portion of the encounter. This means the medical record must clearly demonstrate which provider performed the history, physical exam, or medical decision-making. High-fidelity documentation is essential to prove that the services provided meet the criteria for the billing provider's level of service.
By utilizing an AI medical scribe, clinicians can ensure that the nuances of a shared visit are captured in real-time. The ability to review transcript-backed source material allows providers to verify that the documentation accurately reflects the specific contributions of each clinician involved, simplifying the process of meeting complex CMS requirements.
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Frequently Asked Questions
Transcript-backed documentation, clinician review, and EHR-ready note output are built into every workflow.
How does the AI help with split/shared billing compliance?
The AI captures the full encounter, allowing you to review the transcript and ensure the final note clearly reflects the substantive work performed by the billing provider.
Can I use this for multi-provider encounters?
Yes, our AI scribe records the encounter audio, which you can then review to verify that the contributions of all providers are accurately documented in the final note.
Does the AI ensure my notes are EHR-ready?
Yes, the app generates structured notes like SOAP or H&P that you can review, edit, and copy into your EHR to maintain your preferred documentation style.
Is the platform HIPAA compliant?
Yes, our platform is HIPAA compliant and designed to handle clinical documentation securely while supporting your review process.
Reclaim your evenings from chart notes
Let Aduvera turn visit conversations into a cleaner first draft so you can review faster and finish documentation with less after-hours work.