Wiki Content Based Coding vs Time Coding

[KMilsap]

Looking for some insight here! Coding Medication Management visits for BH using E/M levels. Our providers typically document the time spent with the patient. Some providers I have document a TON, so I feel comfortable giving them a Level 4 when they document that they were with the patient for 30 minutes. Other providers, however, only give me a few sentences but then document they spent 30 minutes with the patient. In this instance, I don't feel comfortable giving them a Level 4, since there is very little to back it up, and end up giving them a Level 3. Has anyone else ran into this? Should I just be giving them the Level 4 since they did indeed spend that much time with the patient? It makes me nervous to do so!

 

[ckeeney]

Are they documenting the time spent on medical counseling/coordination of care and does this meet the criteria stipulated in the guidelines of at least 50% of the time in the visit and documented as such? This does not include anything that might be psychotherapy in which case you would code the E/M based on normal history, exam and MDM scoring with an add-on code for the psychotherapy time. It is not recommended to use the counseling/coordination of care for behavioral health services given the difficulty in interpreting "counseling" and the option of the therapy add-on codes.