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krssy70

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I have a note that supports level billed with documentation, however, at the bottom of this note, the physician dictated that he spend 30 minutes face to face discussing treatment options. If I was to code this note based on time spent face to face counseling/coordination of care, then it would bump up the level to a higher level....
When do you decided when you are going to base your coding on time, or components??????

Thanks for any input on this...........
 
Probably based on the nature of the presenting problem and medical necessity. I would seek the advise of the physician, also. I have encountered this too and the decision did not always lean with the higher code.
 
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I can review with physician on that particular one, but going forward, is there any guidelines that you go by to when you proceed with utilizing the time documented instead of the components. Most of our physicians do not document time, which forces me to utilize the components, however, one physician states the time spent on just about every encounter. I am undecided.....
 
50%

The rule for billing E/M based on time is that if more than 50% of the encounter was spent counseling/coordinating care (and it is well documented) then you code based on time.

I also advise my physician's to briefly summarize the counseling content to support the duration when they code this way.

Hope this helps.
 
My physician states that he discussed the risks, benefits, and options of the procedure. He stated that, after approximately a 45 minute discussion face to face, he felt that all the pts questions regarding surgery have been answered. Proceeding with surgery.
He also states in the note his reviews of Cat Scan, ultrasound, and the review of her case with the Tumor Board. I feel all of these components should justify a level 5.
Would you consider this to be a 99215??
 
Documenting time for counseling/coordination of care

krssy70 said:
I have a note that supports level billed with documentation, however, at the bottom of this note, the physician dictated that he spend 30 minutes face to face discussing treatment options. If I was to code this note based on time spent face to face counseling/coordination of care, then it would bump up the level to a higher level....
When do you decided when you are going to base your coding on time, or components??????

Thanks for any input on this...........
Click to expand...

Merely stating the time spent with the patient is NOT sufficient to code based on time spent in counseling/coordination of care.

In order to code based on time the documentation MUST include ALL the following:
1) total amount spent face-to-face with patient
2) Amount of time spent in counseling/coordination of care (must be GREATER than 50% of total time spent)
3) Nature of the counseling/coordination of care.

Example: I spent 30 minutes face-to-face with patient, 20 minutes of which was for counseling on recommended surgery, including risks, benefits and expected outcomes. (For an established patient this would equal a 99214; new patient 99203.)

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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