Wiki documentation for timed services

[hspaustat]

I continually see deficient documentation for timed services. Instead of documenting time, "units" are recorded. For example: "Ultrasound (97035) was applied to the neck for one unit". This is also copy/pasted 30 times for each of the 30 visits, as is all the other treatments. Besides CPT guidance, Texas Licensing Board, requiring medical records support billing, and OIG audits reports, what other references are available to defend non-compliance. Or would you allow a one unit charge? And what if it were 2 units? I've seen up to 4 units documented instead of actual time. I generally do not accept this type of documentation, especially if over 1 unit and if there is no other supporting documentation reflecting the treatment, such as type of ultrasound, frequency of current for Electrical stimulation, etc.

 

[kdlberg]

As an auditor, I would not accept this. The code specifically says "minutes." Therefore, they need to document the minutes. An estimate is fine--they don't have to say "19 minutes," "26 minutes," "24 minutes and 4 seconds," etc.

 

[sathiya]

As per guidelines, the time spent must be mandatory for all timed codes. Below are references links defend non-compliance

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf

https://www.apta.org/contentassets/...fad/preventing-fraud-abuse-waste-a-primer.pdf (Pg no 9)