EM Coding Alert

Question: We have a provider who sees a lot of pediatric patients with their parents. The parents ask a lot of questions, and the provider almost exclusively bills by time. We know that we must document the total time of the visit, as well as the time spent counseling/coordinating care, and a note about what was discussed. But our physician only documents the total time and doesn’t say what he discussed. Can we still bill this type of visit based on time?

New York Subscriber

Answer: Unfortunately, that documentation won’t work for most insurers. CPT^® says in its introductory notes that “the extent of counseling and/or coordination of care must be documented in the medical record.” Therefore, it’s in your best interest to document all three components to ensure that you’ve met the criteria for billing based on time.

For instance, if the GI physician sees a patient who he diagnoses with Celiac disease, the note might say something like “John presented today with his parents to get the results of his diagnostic testing. I explained that he has Celiac disease and shared information about what that means for his health and how to manage the condition using dietary changes. His family asked several questions about the condition and we spent 40 minutes total during the visit. Of that total time, 30 minutes were spent counseling the family about John’s eating habits, what he must change in his diet, life style changes that will help improve his condition and allow him to gain weight, new restrictions that he faces, and future management techniques that will allow him to thrive.”

Not all notes have to be that lengthy, but must at a minimum cover the total time, the time spent counseling, and a discussion of what was covered.