Wiki Documentation of Time Rule

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tcoder5

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I have a physician who had a level 2 consult but he correctly documented that he spent 90 minutes with the patient. I was always taught that the time documentation trumps the documentation therefore it would be billed as a 99205.. Another coder in the office disagrees. They say it should be billed a a 99202 along with a prolonged service code. Can anyone give me some help?
 
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Just two days ago one of my physicians challenged me on this same issue. I had did some research and it does seem like time is the controlling factor when it is specifically documented for coordinating care and the amount of minutes. After my research I did after all code the level 5 on the note. There are alot of gray areas in coding.
 
Just an idle thought here: Between E/M university and a few education sessions/webinars I have attended, it is always stated that when it comes to an exam, one uses either 1995 or 1997, whichever is more advantageous to the physician. I wonder if that same prinicple would apply here: is it better for the physician to use 99202 and a prolonged service code or to use 99205 assuming all the proper documentation for time-based coding is in place?

Having never seen this rule to use what is more advantageous to the MD in any official sources, I am starting to think that it is an urban legend in much the same manner as the "no double dipping" story. But if not, would that apply to this question?
 
I always go with what can I prove with the documentation, I usually go for the obvious, if the documentation clearly supports a level 2 new patient from the 3 key components which is typically 20 minutes for the provider to perform those key points, but I have 90 minutes total documented
then I have 70 minutes to account for, the 99354 will account for the additional time up to 74 minutes
In this way I feel as though all the providers time has been adequately billed for, the 99205 on the other hand only accounts for 60 minutes of the providers time, so in mind way of thinking it is not about which is the more advantageous but which one accounts for all the work performed by the physician.
 
Thanks to all. I agree this is a gray area. Medicare states that time is a controlling factor but they also state that it must be based on medical necessity. I agree with Debra that the best way to bill this would be to bill 99202 (which documentation supports even though he did document time correctly) & bill the prolonged E&M code. In the event of an audit it would probably be a sure bet to code it that way. Thanks again!
 
Just a little addendum to share some Medicare information regarding code selection based on Time. Medicare wants you to bill the highest E&M level in the code family when time is documented before using the prolonged service code. So if the documentation meets all of the requirements and surpasses the time threshold the 99205 would be the correct code before using the prolonged service code.

This article was updated July 2013. See page 7, the bold type.

Source:
http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/MM5972.pdf
 
Debra,

Is this what you are referring to?

Further, in E&M services in which the code level is selected based on time, you may
only report prolonged services with the highest code level in that family of codes as the companion code.

My physician states that she spent 90 minutes with the patient & over 50% was spent counseling and/or coordinating care. If I am reading the above correctly then I would code it as a 99205. Do you agree? We have had problems getting the prolonged codes paid.

Thank you.
 
Thinking too much?

Interesting discussion, especially as our urgent care doctors are now starting to use prolonged services codes and asking me for guidance. Thanks for the MLN reference - will use that for my next presentation to them.

However, it did raise a question for me. Going back to Debra's example of a 99202 using the 3 key elements and adding a prolonged services code...the chart would support this and it would be correct. However, payers don't see the chart, only a claim. Now, would the 99202 and 99354 on the same claim automatically set off a denial and/or request for additional documentation? They don't know whether the 99202 is based on the three elements or time, so wouldn't they deny the claim and request (maybe) documentation? If so, what a time wasting process.
 
Lance I have never had an issue with coding a low level with the prolonged time, but you do need a diagnosis that can support that lengthy of a visit. With the documentation I have had for these I have always felt that it support the use of the low level and the prolonged better than the 99215. I have only had to appeal a very few and have always been paid on appeal. It does matter what dx code(s) you use though.
 
clarification on start and stop times

Can you please clarify when a provider has to document a start and stop time in the documentation of his note. I always understood total time has to be documented in the record for counseling and coordination of care if it was >50% of the visit. Example: Today's visit was one hour of which >50% was counseling and coordination of care. (Discussion on dx of cancer). A CMS document was brought to my attention that start and stop time must be documented in the note if you are using 99354/99355
I included the documentation requirement from
Related MLN Matters Article #: MM5972
Documentation
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Unless providers have been selected for medical review, they do not need to send the medical record documentation with the bill for prolonged services.
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Documentation, however, is required to be in the medical record about the duration and content of the medically necessary E & M service and prolonged services that you bill.
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Providers must appropriately and sufficiently document in the medical record that they personally furnished the direct face-to-face time with the patient specified in the CPT code definitions.
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Providers should make sure that they document the start and end times of the visit, along with the date of service.


thank you so much
Sheila
 
I'm not completely sure but I've always thought if you are selecting your E&M based on time and not History/Exam/MDM you cannot use the extended add-on codes.
 
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