Wiki Time based coding----please help

[mrsmason95]

Can someone please explain how to code based on time? I am having problems getting my physician and supervisor to understand that to code based on time, you have to have the total time of the encounter AND the time spent in counseling and coordination of care for me to use that to base the code on.

The physician only documented that 45 minutes was spent counseling patient on removal of stent and possible placement of pacemaker. They said this will suffice. I do not agree.


Please comment only if you have experience with this situation.

Thank you

 

[espressoguy]

In order to code based on time, the provider needs to document total time and more than 50% of the visit was spent counselling or coordinating care. Without BOTH of those components, he can not code based on time.

http://www.cms.gov/Outreach-and-Edu.../downloads/eval_mgmt_serv_guide-ICN006764.pdf

Documentation of an Encounter Dominated by Counseling and/or Coordination of Care

When counseling and/or coordination of care dominates (more than 50 percent of)
the physician/patient and/or family encounter (face-to-face time in the office or other
outpatient setting, floor/unit time in the hospital, or NF), time is considered the key or
controlling factor to qualify for a particular level of E/M services. If the level of service is
reported based on counseling and/or coordination of care, the total length of time of the
encounter should be documented and the record should describe the counseling and/or
activities to coordinate care.

The Level I and Level II CPT® books, which are available from the American Medical
Association, list average time guidelines for a variety of E/M services. These times include
work done before, during, and after the encounter. The specific times expressed in the
code descriptors are averages and, therefore, represent a range of times that may be
higher or lower depending on actual clinical circumstances

 

[mrsmason95]

Espressoguy, thanks for your reply. Do you mind giving an example of an appropriate documentation to code based on time. I have told the provider that a beginning and end time needs to be documented, along with how much of that time was spent on counseling and/or coordination of care.