Wiki time based

[JDACPC]

"This afternoon I had the opportunity to spend 60 minutes with the patient and her husband thoroughly reviewing her prior history, current clinical status, laboratory studies, and multiple imaging exams."

It does not state that over half was spent in counseling/coordination of care but can this statement be argued that he spent the entire hour in counseling? The rest of the report reviews studies and treatment options.

Thank you!

 

[syllingk]

To code based on time the statement has to say how much of the visit was dedicated to counseling and coordination of care even if it was 100% it still has to say it and give some description of what was discussed.

 

[MikeEnos]

Time can be used to select the level of code when it is the controlling factor. Here's what your provider needs to document:

1) The total time spent. Not "a lengthy conversation" but how many minutes.
2) That greater than 50% of the visit was spent counseling the patient and/or family or coordinating care.
3) Briefly what topics were discussed. This is normally in the assessment and plan, but if it's not (sometimes I see doctors who basically just list diagnoses in their A&P) it should be clear what was discussed.

If the provider documents this, they can use time to select the code. I would not accept the phrase you quoted as sufficient documentation because it's not clear that most of the visit was spent counseling. You may want to consider billing the appropriate level of E/M code (based on the key components) plus the prolonged services code for the extra hour being spent.