Gastroenterology Coding Alert

Question: Our physician reported G0446 and we were audited. We submitted the records describing the therapy, what was discussed, and next steps, and the payer asked for the reimbursement back because we didn’t meet the documen­tation requirements for the claim. What did we miss?

Codify Subscriber

Answer: It looks like the issue in this case was that you didn’t document the time you spent performing the service. A record of the time you spent is a requirement for G0446 (Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes), said CMS’s Angela James during a May 24, 2016 CMS Provider Minute discussing a very similar case. “If you’re providing a timed service, record the start and stop times, or the total time that you spent,” she said.

Whereas many providers think of recording the time they spent only when billing E/M services based on time, the reality is that this is required any time a code has a timing aspect in the descriptor.