Pediatric Coding Alert

Question: When coding based on time, my pediatricians document the amount of time they spend with a patient. Does a note, such as "Spent 25 min seeing this patient," suffice?

Ohio Subscriber

Answer: No, documentation that supports coding a visit using time as the controlling factor must show the percentage of time that was spent face-to-face with the patient on counseling and/or coordination of care versus the total visit. For a visit to qualify for time-based outpatient coding, the counseling must comprise more than 50 percent of the face-to-face encounter.

For instance, the physician could write, "Spent 25 min total face-to-face time/15 minutes counseling." This note clearly shows an auditor that the visit supports time-based coding.

Don't miss: Chart reviewers will want some brief description of what the physician reviewed and provided. Therefore, you should encourage your pediatricians to indicate two items:

1. the counseling/and or coordination of care topic, such as discipline, biting avoidance

2. a general reference to the counseling/coordination of care provided, such as discussed parental concerns, treatment options, follow-up.