Urology 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?

Maryland 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.

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.