Orthopedic Coding Alert

Question: If a physician spends 45 minutes reviewing a patients current situation and answering the patients questions, can the time be billed? If so, is it billed by time, or is the exam, history, etc., included?

Montana Subscriber

Answer: As long as more than 50 percent of the visit was spent counseling the patient, time can be billed. One or more of these purposes outlined by the American Medical Association must have been discussed during the visit:

diagnostic test results;

impression and/or recommended diagnostic studies;

prognosis;

risks and benefits of management options;

instructions for management and/or follow up;

importance of compliance with chosen management options;

risk factor reduction; and/or

patient and family education.

When time is the prevailing factor, the discussion, history, exam, decision-making and time spent with the patient must all be documented.