TTcpc
Guru
Hello,
I am trying to find some supporting information regarding prolonged services documetation in the inpatient setting so that we can make sure we are compliant with its use. If you have two physicians in the same group or even the same physician who sees the patient twice in the same day and the first visit of the day meets the documentation requirements for the level of E/M service billed (not based one time) and physican B comes in for a new problem or change in the patients condition requiring the physician's presence (medically necessary), can physician B bill prolonged services if physician A does not document his/her start/stop times but their visit meets the documentation level requirements and the time spent by physician B meets the time threshold with documented in/out times?
Example: Dr. A sees the patient today and documents a visit that meets the criteria for a 99233 without the use of counseling time and does not document the time spent with the patient. Later in the day, Dr. B is contacted because the CT ordered by Dr. A has come back and in addition to the CVA the patient has suffered and being anticoagulated for, she has abdominal pain and the CT results show a hematoma with active bleeding into the abdomen. Physician B clearly documents in/out times spent with the patient/family re-examining the patient and explaining the treatment option changes due to this new development, as well as ordering transfusions and making plans to reverse anti-coagulation. Time spent by Dr. B at the bedside doing this is 43 minutes with an additional 27 minutes of time documented because Dr. B is called back yet again because the patient has become tachycardic, HgB has dropped further, and bm with blood.
Any supporting documentation would be greatly appreciated.
Thank you!
I am trying to find some supporting information regarding prolonged services documetation in the inpatient setting so that we can make sure we are compliant with its use. If you have two physicians in the same group or even the same physician who sees the patient twice in the same day and the first visit of the day meets the documentation requirements for the level of E/M service billed (not based one time) and physican B comes in for a new problem or change in the patients condition requiring the physician's presence (medically necessary), can physician B bill prolonged services if physician A does not document his/her start/stop times but their visit meets the documentation level requirements and the time spent by physician B meets the time threshold with documented in/out times?
Example: Dr. A sees the patient today and documents a visit that meets the criteria for a 99233 without the use of counseling time and does not document the time spent with the patient. Later in the day, Dr. B is contacted because the CT ordered by Dr. A has come back and in addition to the CVA the patient has suffered and being anticoagulated for, she has abdominal pain and the CT results show a hematoma with active bleeding into the abdomen. Physician B clearly documents in/out times spent with the patient/family re-examining the patient and explaining the treatment option changes due to this new development, as well as ordering transfusions and making plans to reverse anti-coagulation. Time spent by Dr. B at the bedside doing this is 43 minutes with an additional 27 minutes of time documented because Dr. B is called back yet again because the patient has become tachycardic, HgB has dropped further, and bm with blood.
Any supporting documentation would be greatly appreciated.
Thank you!