Wiki Coding with Time

[emreed99]

Can you code an E/M visit strictly off of time???

An example is that a patient came in to our office and her chart supports an expanded problem focused history, a problem focused exam, and MDM is not documented. In the chart it states "Most of this 30 minute visit was spent in counseling and cooridination of care."

The Dr wants to code this as a 99214, based strictly off of time. I disagree. I don't believe you can code strictly off of time. Am I wrong?

Thank you!!

 

[Youngmedconsult]

Medicare's documentation of time

The other thing to remember is if you are looking at a patient who has Medicare (or insurances who follow Medicare's E&M rules) the chart must have 2 things to have compliant documentation when time is used as the rationale for code selection: #1) total time of visit #2) number of minutes of counseling and coordination of care or a % of the total time.

MCM Chapter 1 Sec 30.6.1.C

The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.

 

[opclaire]

2011 rules on level of care by time

I understand there are new 2011 guidelines for using time to determine level of care. Would you be able to provide some insight?

thank you!