Wiki Billing By Time

[ieshiarenee]

Hello everyone,

If a provider documents a full chart with an HPI, ROS and exam, but also documents time, what do you code by? I'm thinking the time documentation would trump the chart note documentation.

Any inputs are appreciated.

Thanks so much!
Ieshia C.

 

[Lukelie]

all encounters should have the elements of history, exam, and medical decision making. To code based on time, they would have to include the criteria to support it e.g. treatment/management options, prognosis, compliance with treatment options, etc and to document the total time and time spent counseling. Medical necessity is the overreaching criterion e.g. I dont' think it would be correct to have a provider bill a 99214 based on time for a self limited/minor problem. CMS has some updated information regarding the use of time. Hope this helps.

 

[ieshiarenee]

I understand what you're saying. But let's say a patient came in for pneumonia, the documentation and MDM supports a level 4, but the provider documented time to be a level 3. Which one do you code by, time or the documentation?

 

[pclaybaugh]

Time is only a contributory factor in determining which level of evaluation and management (E/M) to report for a visit. Usually, a level of E/M service is determined by the key components of history, examination, and medical decision making. However, if you end up spending greater than fifty percent of the total visit counseling/coordinating care, you can use time as the key factor in determining the level of E/M service that you report. Using time to code E/M services can be a slippery slope unless it is done correctly.