Wiki E&M-Time Coding

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My providers put the following statement on all notes (different times of course for different levels) and expect me to code on time. I do not agree with them. Can I please get some input and/or information I can give them to prove my point.

"I had a lengthy and detailed discussion with the patient regarding the above findings. Appropriate guidelines reviewed. Options/risks/benefits were discussed and all questions answered. Total time was 30 minutes."

I feel that this is very vague and not appropriately documented for time coding.

Please Help!!!
 
Hi Kirchmore,
What are the above findings? What type of visit was this follow up, new or est. patient Evam Mgt visist. Also what is the HPI and ROS if applied here? I d leave the provider s allotted time alone but assign dx and or CPT code from whatever is his or her above findings. You need to tell us a bit more.
Lady T
 
Hi Kirchmore,
What are the above findings? What type of visit was this follow up, new or est. patient Evam Mgt visist. Also what is the HPI and ROS if applied here? I d leave the provider s allotted time alone but assign dx and or CPT code from whatever is his or her above findings. You need to tell us a bit more.
Lady T
I'm looking at one now, the patient is in the office for circumcision post surgery follow-up. He is out of post-op period. The HPI is copied and pasted from her previous note prior to surgery. She added: He is now s/p circumcision on 8/8/23 and is doing well. He has no complaints. The ROS is also copied and pasted from previous note. The Assessment/Plan is: Male circumcision Z41.2, Doing well, elects to RTC PRN. She used the exact statement from my first post except the time is changed to 20 minutes and she has it coded as a 99213.

I hope all this makes sense.
 
Hi KBirchmore

I 'd not give it CPT 99213 either. And since follow up and focused on same dx problem I 'd use CPT 99212 and code dx as Z41.2 as dx. but wonder why he got the circumsion.....was it like DO of Penis dx N48.89? Usually use the definitive dx problem then dx Z41.2 as 2nd dx. If he was out of post op time slot care then use CPT 99024 and no charge.
Well hope helped you a little bit more
Lady T
 
Last edited:
To me, this is now getting into more than a coding question. Medical necessity is the overarching criteria. I personally do not feel that a coder is qualified to override the medical necessity of a service a physician provided.
I'll instead focus on the coding aspect. The time statement is supposed to include the work performed. While what the provider put is not "wrong", there would be better ways to word it. Here's what I recommend to my providers when putting a time statement:
"I have personally spent ## minutes of time today on the encounter excluding any separately billed tests or procedures. This work included: reviewing prior records, obtaining and reviewing history, performing exam, counseling patient, ordering tests or procedures, documentation and care coordination."
I further advise if the time spent seems unusually long to add explanation. Example "Patient had multiple additional in-depth questions regarding activities allowed during the recovery period which contributed to the overall time." "After discussing surgery risks with patient, she was emotional and very concerned. She asked me to call each of her 2 daughters separately and explain the R/B/A of surgery to them as well." Anything that could help explain what could seem like a lengthy visit.
Now let me take off my coding hat and put on my common sense hat. If the patient was returning after a surgery and had NO complaints and doing well and no further treatment, why would it take the provider 20 minutes?? I have my coders work with specific clinicians on a regular basis to help with documentation and compliance moving forward. If you are regularly seeing time documentations that are "suspicious" in your opinion, I would discuss in a very non-confrontational way with the provider. Be inquisitive, but not questioning the provider's decisions. Explain you understand how hard they work, and you want to ensure proper payment for all that hard work. Less than ideal documentation is a recipe for inaccurate coding and payment.
 
To me, this is now getting into more than a coding question. Medical necessity is the overarching criteria. I personally do not feel that a coder is qualified to override the medical necessity of a service a physician provided.
I'll instead focus on the coding aspect. The time statement is supposed to include the work performed. While what the provider put is not "wrong", there would be better ways to word it. Here's what I recommend to my providers when putting a time statement:
"I have personally spent ## minutes of time today on the encounter excluding any separately billed tests or procedures. This work included: reviewing prior records, obtaining and reviewing history, performing exam, counseling patient, ordering tests or procedures, documentation and care coordination."
I further advise if the time spent seems unusually long to add explanation. Example "Patient had multiple additional in-depth questions regarding activities allowed during the recovery period which contributed to the overall time." "After discussing surgery risks with patient, she was emotional and very concerned. She asked me to call each of her 2 daughters separately and explain the R/B/A of surgery to them as well." Anything that could help explain what could seem like a lengthy visit.
Now let me take off my coding hat and put on my common sense hat. If the patient was returning after a surgery and had NO complaints and doing well and no further treatment, why would it take the provider 20 minutes?? I have my coders work with specific clinicians on a regular basis to help with documentation and compliance moving forward. If you are regularly seeing time documentations that are "suspicious" in your opinion, I would discuss in a very non-confrontational way with the provider. Be inquisitive, but not questioning the provider's decisions. Explain you understand how hard they work, and you want to ensure proper payment for all that hard work. Less than ideal documentation is a recipe for inaccurate coding and payment.
I appreciate your reply. I'm not questioning the medical necessity and I do not believe I am qualified to override the physician. I am questioning how they have the time documented when my common sense is saying, why did it take 30 minutes for this patient. Your suggestions are very helpful. Thank you!
 
Hi KBirchmore

I 'd not give it CPT 99213 either. And since follow up and focused on same dx problem I 'd use CPT 99212 and code dx as Z41.2 as dx. but wonder why he got the circumsion.....was it like DO of Penis dx N48.89? Usually use the definitive dx problem then dx Z41.2 as 2nd dx. If he was out of post op time slot care then use CPT 99024 and no charge.
Well hope helped you a little bit more
Lady T
Thank you for your reply.
 
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