Wiki Time based E/M

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sorcha48

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We have some doctors that do not put in their documentation the time spent, but based on averages we know that they spent more than 50% counseling.

Example:
discussion with pt and family on hospice placement
discussion with staff concerning pt's status
discussion with oncologist

If there is nothing from the doctor on time spent, can the time based coding be used be inserted by the coder?
 
If total face to face time is not documented then there is no way for you to use time based coding. It cannot be used based on a supposition. If this is an inpatient then you must have the total bed time with the patient plus the floor time must also be documented and then added to the bed time. unless you have met the parameter of 30 minutes beyond the visit level time then there is no prolonged time that can be added.
 
Inpatient

Be careful with INPATIENT coding ... some payers will only allow you to count face-to-face time.

I absolutely agree with Debra ... NO, the coder can not add time. The physician is responsible to accurately document his/her services. The coder is responsible for translating that documentation into the correct code.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Thank you. I thought as much. Does anyone know of documentation? I have a coder that needs to see the rule.
 
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