Wiki Level of E/M needed

Create Wiki
T

tag60

Guru
Messages
150
Location
Santee, CA
Best answers
0
Does this note satisfy guidelines to code E/M based on time?

S: NEW patient is in requesting refill of medication. Has had prior refills at X pharmacy. Had a weightlifting injury. Found of all meds he has tried, this one works best for neck and back spasms.
O: Neck: No notable atrophy. Shoulder exam deferred--couldn't do today due to extended time getting history and backlog of patients. He's physically fit and easily ambulates.
A/P: Back injury/neck spasms.
Utox, TSH, LFTs. Flexeril for spasms.

"30 minutes spent in initial history today and assessment of a complex situation."

My supervisor says the statement regarding 30 minutes is enough and to code the E/M level based on that. She says a statement about "more than 50% of time spent in counseling and coordination of care..." is not necessary.

This issue comes up often with this doctor who gives minimal documentation but at end of note gives a statement about how much time was spent. Often he does not describe what exactly that time entailed other than to say "discussed extensively with patient" or "spent over X minutes with patient." (Discussed WHAT is not further clarified.)

I need some input on this please! How would you code the above? Thank you!
 
No that is not specific enough. The amount of time it took to take the history is what took so much time and his backlog of patients. I sure hope the office is not audited. NO way he's getting anywhere close to a level 5 with this


From the 1997 Guidelines

https://www.cms.gov/outreach-and-ed...n/mlnedwebguide/downloads/97docguidelines.pdf

If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (faceto-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.

Based on my extremely limited E&M experience, I'd be surprised if its any higher than a level 1.

Looks like a problem focused exam (barely looked at neck) which automatically brings it down to a 1 for new patient
 
Last edited:
That's a usual statement seen, and although it appears like they think they might be covering all their bases with this statement, there'd better be specificity in the coding to indicate as CK submitted from the 1997 guidelines above. Such blanket statements as the office is using justdo not satisfy the criteria. Without specificiity it is a lower level visit. Oh sure, it can be billed at a higher level, but should an auditor come knocking at the door, there will be a rude awakening! Whan CAN be done is not always what SHOULD be done and in this case, such coding/billing scenarios need a SERIOUS review!
 
This is a new patient and there is no history documented. He states 30 minutes spent collecting it , but what exactly was collected. You need HPI, ROS, and PSFSH, there us barely any exam, and I see no treatment plan. This is not a billable encounter for a new patient.
In addition to bill a visit on time it must be based on counseling and coordination of care not taking a history.
 
If you're coding based on time the following statement is required. " X amount if time was spent with the patient and greater than 50% of time spent in counseling and coordination of care." I would also suggest that the provider document a brief description of what he spoke with the patient about.
 
You must log in or register to reply here.
Top