Wiki Time as the "fix"

[mikesyzf]

One of our providers consistently leaves the ROS and EXAM portions of their Office Visits "blank". I have spoken with this provider regarding this issue. As part of our discussion, the physician inquired of the amount of "time" for these typical office visits. I provided the physician with the appropriate time amounts for new and established visits, levels 1-5. I was excited to see the physician's upcoming "improved" office visit dictations. Instead of having the "ROS" and "EXAM" elements filled in, the physician again, leaves them blank but has now added " Greater than 60 minutes face to face time was spent with the patient, more than half in counseling and coordination of care". Even though the document by itself would be minimal, this physician is coding them as level 4's and 5's now that the "counseling and coordination of care.... " was added. Anyone else experience this and how did you correct it?

 

[CatchTheWind]

I see no problem with this as long as
1) he really did spend that much time with the patient,
2) at least 50% of that was spent on counseling or coordination,
3) it was medically necessary to spend that much time (ie: if he just chats with the patient for part of the hour, that's not billable time because it wasn't medically necessary to spend all that time), and
4) he documents what he counseled about or coordinated.

 

[CodingKing]

Time is not a fix to poor documentation. If ROS and EXAM was done but not documented that is a major issue as well. Coding based on time is not replacement for documentation. Consistently coding based on time would be abnormal.

This not sufficient for time based billing:

"Greater than 60 minutes face to face time was spent with the patient, more than half in counseling and coordination of care"

The actual time of the visit must be documented along with what the counseling and care coordination consisted of.

Here are some documentation examples:

http://www.gastro.org/news_items/clarification-on-time-based-billing

Example: Patient returns to clinic following a colonoscopy done for rectal bleeding, abdominal cramping and diarrhea. Symptoms have improved, but biopsy results show significant ulceration of colon consistent with ulcerative colitis. Patient looks well and is in no acute distress, vital signs are stable. I spoke with the patient and her husband at length regarding new diagnosis of ulcerative colitis. Currently, her symptoms have improved, but I would like to start her on Asacol 2-400mg tabs three-times daily until flare resolves. We discussed medication side effects and disease progression — all questions were answered. I spent a total of 30 minutes with the patient and would like to see her back in clinic next month. Time spent discussing new diagnosis and treatment options coded as 20 minutes.

http://chicago.medicine.uic.edu/Use...liance/Documentation for Time Based Codes.pdf

Established Patient Example: “I spent 15 minutes (total time 25 minutes) discussing diagnosis of hypertension, prognosis and treatment alternatives. Answered patient’s many questions concerning results of diagnostic tests and new medications. Discussed and gave pt. information on diet. Stressed importance of compliance and follow-up with above. ”

New Patient Example: Spent 30 minutes of 35-minute visit discussing with new OB transfer patient our practice style. Answered many questions related to care and follow up provided by this practice. Gave patient information on pregnancy and delivery.