# 99215 / Documentation of time spent w/ patient



## EK226

Hello, 

I have a question about using the code 99215 for an office visit.  When I read the description it states that they physician typically spends 40 minutes face-to-face w/ the patient.  How specific does the physician have to be when he documents his time spent w/ the patient?   

On the office notes, it just states "time in" and "time out"--- which does total more than 40 minutes.  Is something like this acceptable or does the physician need to be more specific and break down the total time spent w/ the patient? 

Thanks, 
Emily Kress, CPC


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## mitchellde

As long as the time in/time out is documented byt the physician as his/her total face to face time, the it can be use in the calculation.  However time spent alone is not a consideration for visit level.  First a visit is determined by the documentation of the three key components, then if counseling or coordination iof care is docuemnted and is considered the key/controlling component, (50% or more of time spent) then time is used as the THE component to determine the visit level.


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## EK226

Hi Debra, 
thank you for your reply regarding this office visit.   I am still trying to figure out if 2 out of the 3 key components are even being met.  The doctor has seen the patient for a total of 5 times and is billing 99215 for all 5 of the office visits.  When I look at the CPT book I see that for 99215 the key components for 99215 are a comprehensive history, comprehensive examination, and MDM of high complexity.   

The patient is being seen for 1st and 2nd degree burns on both of his hands and wrists.  It looks like at each office visit the burns were cleaned w/ antibacterial soap and then new dressings were applied, the doctor also mentions in each note that he is instructing the patient & his wife on how to change and apply new dressings.   He also takes the patients vital signs, and then performs an examination of the burned areas.  Does this constitute a "comprehensive" history and exam?  I thought that for a comprehensive history the physician needs to perform a complete PFSH as well? 

I'm not sure if I am overthinking this or not, but I can't seem to justify 99215 for all 5 of the visits.  The burned areas were never infected, it appears they are simply monitoring the areas for infection but the fact that they do clean and change the dressings at each visit along w/ informing the patient on how to take care of his wounds makes me think that it is a little more involved and not just your typical office visit...

I've been trying to comprehend this for a while, and I think I'm getting myself more confused...

Emily


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## mitchellde

hmmmmmm I see your point, so what visit level do you get from the encounter?  Given the 2 out of 3 are you getting a level 2 or 3? Also is the physician documenting the time spent with the patient.  It is entirely possible for this to be a level 5 but we need to figure it out and verify.


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## EK226

Hi Debra, 

I am able to determine that the exam is comprehensive, and by looking at the MDM table in the CPT book, I had a question about the "extensive" levels.   How would you know if the # of diagnosis or management options is extensive?  How would I also know if the amount of the complexity of data to be reviewed is extensive as well?  Would these be things that are only up to the physician's discretion since he is the one making the decisions?   I still cannot justify the comprehensive history since the physician does not note anywhere that he performed a full PFSH.   

The physician is documenting his time, but he only states it on the note as "arrival time: 9:30 am departure time 10:45 am."  he doesn't specifically break down the time of the entire visit, which I thought was something he was supposed to do. 

Thanks, 
Emily Kress, CPC


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## mitchellde

in MDM section it is more subjective as to how much can be extensive.  I know some people use a point system and some programs to this as well, but it is important to remember that the guidelines do not specify what it means to be limited vs moderate vs extensive.  You need to determine the criteria and be consistent with your logic.  If I were to request your office notes for an audit, how would you explain the level of visit charged, how would you justify it?  So # of dx is the number of dx reviewed or managed with the patient , and the management options, would br the extent of information regarding those dx, as far as how he was going to be managing or treating at that visit and in the future.  For information complexity, discussion with the spouse and how detailed was that etc.  As far as History goes, since this is an established patient then you do not need a history review.  With a burn patient it would be really easy to be very complex.  As far as the time spent, is he documenting the patient's arrival to the office or his arrival to the exam room?  It needs to be clear that this was all his face to face time.  What I see here is 75 minutes, If the visit is a level 5, then you can still append prolonged time 99354 and I would if the documentation is good.  Go read it again, and write up your own audit just as if it had been requested by a payer and you need to verify the level.  FYI anytime a payer requests charts for review I always add my own audit of the level to show them how it does meet the level charged.


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## EK226

Hi Debra, 

Thank you for your advice...I think that is a good idea to write it out, and look at it again.   I think that is why I'm so hesitant on agreeing with 99215 because I need to make sure I can back it up if someone questions me on my reasoning. 

Thank you again for all of your help, I really appreciate it!!!  

Emily Kress, CPC


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## FTessaBartels

*Coding based on time spent in counseling/coordination*

In order to code based on time spent in counseling/coordination of care - THREE things must be present:
1) total amount of face-to-face time spent with patient
2) amount of face-to-face time spent in counseling/coordination of care (must be MORE than 50% of total time)
3) summary of nature of the counseling/coordination

For example:  I spent 45 minutes in direct face-to-face time with patient, 25 minutes of which was spent in counseling regarding burn treatment, minimizing scarring, potential need for further surgery, risks and benefits of various treatment options. 

From the limited info you've provided your physician is not meeting any of these requirements (I'm not certain that the time in/time out is doctor's face-to-face time with patient.)


The entire time spent must be face-to-face with the physician in direct patient care ... can't be in the lab getting bloodwork, can't be in the exam room without the doctor (e.g. give patient an analgesic and leave for 15 minutes before returning for procedure). I find it hard to believe that the physician would meet this standard on EVERY one of these visits. I'd be tempted to look at other charts of patients on the same date of service and if the times overlap - BINGO - there's a huge problem.

Our surgeons have a burn clinic and we usually just code the burn treatment codes ... the E/M that is provided is directly related to these dressing changes and not separately reportable.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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