Wiki Time based coding

[RABBIT2020]

With time based coding is it only the time that matters or should there be other elements present in the progress note to be sufficient for an E/M office visit code?

 

[Orthocoderpgu]

You just opened a pandora's box. For right now in order to use time as the factor for choosing an E/M code, the time spent with the patient is meaningless. If over 50% of the time spent with the patient is counseling the patient, then you can use time as the factor for choosing the E/M code, but that does not mean documentation is any less important or that medical necessity is not met. Keep in mind the documentation must always support the code being billed. It's not enough for your physician to do it, they must do it and document it. They must document the total time of the visit & that more than 50% of the visit was spent counseling the patient. In addition to this the physician also needs to document specifically what topic the patient was counseled on and I would include a small example of any recommendations made. Keeping in mind that "medical necessity" also needs to be met. For example, would it be medically necessary to counsel a patient for 45 minutes on how to deal with a sprained finger or a bug bite? No. Time based coding is not a free-be where the doc does not have to documents anything but still be able to bill. You still have to cover all your bases.