Wiki E/M time based coding

[Greenpiper]

Issue: some of our providers have started using time consistently to document their charts. They are using a canned statement "I have spent a total of XX minutes face to face with the patient, reviewing past documentation, managing labs/xray orders, coordinating with other healthcare professionals and / or documenting today's encounter." No where in the chart is there supporting documentation for the activities listed in the canned statement and most are recording 45+ minutes (approx. 90%+). We have been instructed to code based on the time provider supplies as "It is on the provider to support in an audit situation that they were actually in the pts chart for xx time. The legality falls to the provider not the coder." Having a hard time with this as I feel like coders WOULD be responsible for knowingly coding the chart incorrectly? Maybe we are over thinking this issue but I have not been able to find anything definitive discussing this. What would an auditor be looking for in these cases?

1. Urinary incontinence, unspecified type (Primary)
Assessment & Plan:
Patient presents with complaints of urinary incontinence. No lumbar injuries or factors back pain. No trauma.
Plan
-Urine dipstick
-Urine culture
Orders:
- POCT Urinalysis Dipstick Non-Automated
- Culture, Urine, Comprehensive; Future
- XR Lumbar Spine 2 - 3 Vw
2. Chronic pain of left knee
Assessment & Plan:
Patient presents with chronic left knee pain. Patient feels her knee gives out especially walking downhill. Patient has less difficulty walking up or. No trauma or injuries to her left knee. Patient is using a wheel walker for ambulation. This is her baseline.
Plan
-Left knee x-ray
-Possible physical therapy referral
Orders:
- XR Knee Left 1 - 2 Vw
I have spent a total of 45 minutes face to face with the patient, reviewing past documentation, managing labs/xray orders, coordinating with other healthcare professionals and / or documenting today's encounter.

Orders Placed
POCT Urinalysis Dipstick Non-Automated
Culture, Urine, Comprehensive
XR Knee Left 1 - 2 Vw
XR Lumbar Spine 2 - 3 Vw
All Encounter Results

Medication Changes
None
Medication List

Visit Diagnoses
Urinary incontinence, unspecified type R32
Chronic pain of left knee M25.562, G89.29

 

[kdlberg]

If I were auditing your providers and saw this exact same statement after 5 or so charts, I would wonder if they actually did the work. By the time I get to the 15th chart, I see the first few words and don't even bother to read the rest.

Canned statements are a good starting point but they need to be adjusted to what was done at that visit. If they coordinated with another provider, who was it and what was coordinated? Reviewing old records--what was found? If nothing clinically relevant was found, state that. Was an exam done? Counseling and education, what did you talk about? It doesn't have to be a novel, something like "counseled on DASH diet, start on moderate exercise 2x week" is sufficient.