Wiki MDM VS TIME

[mskitaly09]

Patient came in for leg pain been going on for about two weeks. History of rheumatoid. Pain is getting worse. Provider treatment plan 1. arthritis of right knee w/rx 2. Essential HTN-stable 3. prediabetes-stable. Total time spent 30 mins. This provider using time for every encounter always 30 mins. If pt came in for acute prob and rx was given no labs were done to determine if the HTN and prediabetes were stable. Should I use provider time or based it on MDM which would be 99213 for the arthritis of right knee and rx management

 

[csperoni]

When a note can be leveled by either MDM or time, you may use whichever is more advantageous.
That being said, if all the notes from the provider indicate something highly suspicious, the provider should be educated and reminded about accurate documentation. What do I mean by highly suspicious? Here are some examples:

• Appointments are booked every 30 minutes, occasionally double booked, yet documentation times indicate longer than 30 minutes for every patient.
• Impossible days - meaning if you were to add up all the times for the day, it would not be possible to have spent that much time in a day.
• Every single chart has exactly the same amount of time. Really? No one was 29 minutes? No one was 33 minutes? The patient where the provider had to evaluate multiple problems/treatment options for a nervous patient took exactly the same amount of time as a patient who needed one prescription renewal?

 

[mskitaly09]

When a note can be leveled by either MDM or time, you may use whichever is more advantageous.
That being said, if all the notes from the provider indicate something highly suspicious, the provider should be educated and reminded about accurate documentation. What do I mean by highly suspicious? Here are some examples:

• Appointments are booked every 30 minutes, occasionally double booked, yet documentation times indicate longer than 30 minutes for every patient.
• Impossible days - meaning if you were to add up all the times for the day, it would not be possible to have spent that much time in a day.
• Every single chart has exactly the same amount of time. Really? No one was 29 minutes? No one was 33 minutes? The patient where the provider had to evaluate multiple problems/treatment options for a nervous patient took exactly the same amount of time as a patient who needed one prescription renewal?

Thank you for your feedback!