Wiki Documentation of time

[Lisapurple216]

I'm wondering how everyone requires their providers to document the time element when coding on time. Do you require is to be done right in the same phrase" 30 minutes spent face to face with patient, greater than 50% in counseling and coordination" or is it documented somewhere else in the note. I audit for two different offices, one documents as above, the other has a documentation of time at the top of the record then just puts the rest of the phrase along with what was discussed later in the note. My concern would be that no one outside of their office would understand what the time at the top represents. Thanks in advance.

 

[Pathos]

I don't see either in CMS E/M guidelines or in the CPT book that the time and documentation have to be in the same phrase as the other. However, remember that whoever audits the chart could likely get confused and if they don't see the proper documentation, the provider will not get credit for using Time.

I just think it would be good practice to keep both together (time and documentation).

 

[Lisapurple216]

Thank you, my thoughts as well.

 

[Chelle-Lynn]

We require one of the following formats from our providers:

Example 1 Spent 45 minutes with thepatient and 50% was spent providing DM counseling
Example 2 Spent 30 minutes with thepatient in which 15 min were spent with patient reviewing all medications
Example3 Spent 40 minutes with thepatient with 30 minutes spent with patient reviewing all test results and plan of care.