Wiki EM calculation based on time range when the the provider documented time range that is overlapping from one code range to another

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jothishjb

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One of our provider documented a time based note in an established patient visit 'Office visit lasted approximately 35-40 minutes.' Tru-code showing time range as below. Please let me know which is the correct EM code for this scenario as we are taking 35 mins then it will lead to level 4 and if we are taking 40 mins then it will lead to level 5. Somebody please suggest your thoughts.. Thanks in advance.

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I don't know that this situation is addressed in guidelines anywhere, but in my opinion this falls into the category of 'unclear documentation'. My advice would be to talk to the provider and let them know that you can't accurately select a code unless you have an accurate amount of time documented in the record.

I would probably also tell the provider that in cases where they document a range like this, that I would code based on the lowest amount of time documented since you don't really have a definitive total time and have to go with the minimum given. I believe that's the approach an auditor would likely take in this situation.
 
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jothishjb said:
One of our provider documented a time based note in an established patient visit 'Office visit lasted approximately 35-40 minutes.' Tru-code showing time range as below. Please let me know which is the correct EM code for this scenario as we are taking 35 mins then it will lead to level 4 and if we are taking 40 mins then it will lead to level 5. Somebody please suggest your thoughts.. Thanks in advance.

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Take this time to educate your providers in the proper documentation of time based E/M 2021 . Total time is to be documented , not an approximation of time spent. In this case, since it's already done , I would go forward in coding them or giving them the lowest level where the time meets. This will be a lesson for the future for them.

Hope this helps. :)
 
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lcolborn said:
Take this time to educate your providers in the proper documentation of time based E/M 2021 . Total time is to be documented , not an approximation of time spent. In this case, since it's already done , I would go forward in coding them or giving them the lowest level where the time meets. This will be a lesson for the future for them.

Hope this helps. :)
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I agree for accurate coding and reporting documentation must be clear however, in this case I would assign code 99214 (30-39min).
 
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jothishjb said:
One of our provider documented a time based note in an established patient visit 'Office visit lasted approximately 35-40 minutes.' Tru-code showing time range as below. Please let me know which is the correct EM code for this scenario as we are taking 35 mins then it will lead to level 4 and if we are taking 40 mins then it will lead to level 5. Somebody please suggest your thoughts.. Thanks in advance.

View attachment 5371
Click to expand...
I was always under the impression you could take the higher level but you must have supporting documentation.
 
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