jcochran
Guest
I originally posted this in the Behavioral Health Thread since we are an Community Mental Health Center, but was hoping to recieve more input here possibly. Thanks for your input in advance
We would like to start using the time based E/M billing, I have a quick question. Both the 1995 and 1997 CMS guidelines state that:
D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CARE
In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.
!DG: If the physician elects to report the level of service based on counseling
and/or coordination of care, the total length of time of the encounter (face-to-face or
floor time, as appropriate) should be documented and the record should describe
the counseling and/or activities to coordinate care.
I am unsure whether or not we would still need to meet the 3/3 or 2/3 guidelines as far as history, exam, MDM, etc... I have been unable to find a definitive answer anywhere.
As long as we document total face to face time with client in counseling and/or coordination of care, as well as medications/care discussed, what else do we need to document on each visit?
We would like to start using the time based E/M billing, I have a quick question. Both the 1995 and 1997 CMS guidelines state that:
D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CARE
In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.
!DG: If the physician elects to report the level of service based on counseling
and/or coordination of care, the total length of time of the encounter (face-to-face or
floor time, as appropriate) should be documented and the record should describe
the counseling and/or activities to coordinate care.
I am unsure whether or not we would still need to meet the 3/3 or 2/3 guidelines as far as history, exam, MDM, etc... I have been unable to find a definitive answer anywhere.
As long as we document total face to face time with client in counseling and/or coordination of care, as well as medications/care discussed, what else do we need to document on each visit?