Wiki E/M selection by Time statement

[rebrikv1]

Is it acceptable to use such provider statement to support CPT 99215 (as an example): "I spent 45 minutes during the day of the visit providing care for the patient. This time may include any or all of the following activities: reviewing past information; obtaining history and/or reviewing separately obtained history; performing a medically appropriate examination; counseling and educating the patient/family/caregiver; ordering medications, tests or procedures; referring and communicating with other health care professionals; documenting clinical information; independently interpreting results and communicating them to the patient/family/caregiver; care coordination." ?

 

[amyjph]

My view is no. It is just a template blurb that says "may include any or all". What did it actually include? We have no idea. How long did they spend on reviewing past info or notes? No clue. How long did they spend on the exam, orders, tests, communicating with others, how long did they spend documenting? No clue. Did they do all of those things listed? I have no idea.

This is not acceptable.

It's great the total time is listed but it does not tell an auditor specifics, it's "cookie-cutter".

 

[csperoni]

I agree with @amyjph . I would recommend: This time includes the following activities: list all the activitities. AND THE PROVIDER SHOULD DELETE ANY ACTIVITIES THEY DID NOT PERFORM FOR THIS PATIENT/ENCOUNTER. But "may include" does not tell me what the provider actually did.