Wiki coding time

[samyjm13]

The Dr. stated in the document that "this is a discussion only visit" for lab results and did not document the time. Dr. did doc. an Assessment with 2 history of Dx's. Now, I feel without the time an E&M level is hard to come to. Any suggestions on time based coding.\

Thx

 

[mcandia]

Coding time

To bill based on time the discussion / counseling has to dominate (> 50%) of the encounter.

The areas of discussion / counseling should be described in detail.

The total time of the face to face encounter should be documented i.e, I spent 40 minutes with the patient, 25 minutes were spent counseling the patient regarding ............

Maria

 

[janellkangas]

It appears that the doctor intends to bill based on time based on his "discussion only visit". You just need to tell him that in order to bill based on time he actually needs to document the time. Maria has the correct statement for time above.