Wiki Time Driven E/M

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jennyifer

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Hello fellow members,

I was going over the material for the E/M audit strategies webinar, hosted by Christine Ann Pfeifer. This is regards to the “Billing based on time” section. It says the summary of the discussion must be documented, can this documentation be taken from the HPI, or a “patient instruction sheet?”
 
No

The physician must document the nature of the discussion/counselling/coordination of care that took place during the visit.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Can the documentation needed for counseling/coordination of care be taken out of the HPI or does it have to be separate from the HPI? For example, 30 min spent face-to-face with patient, half the time was spent counselling the patient on controlling diabetes.
 
The physician must document what he discussed with the patient, ie treatment options, risks and benefits of different treatments etc. If all he documents is what you have stated he cannot bill based on time.
 
Yes, but he writes some of the treatment options, what he discussed etc either in his HPI and a patient instuction sheet (directions he gives the pt). He considers this as his documentation for time. Is that ok?
 
reference

http://www.cms.gov/manuals/downloads/clm104c12.pdf

section30.6.15.1 subsection D. Documentation states.

"Documentation is required in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services billed. The medical record must be appropriately and sufficiently documented by the physician or qualified NPP to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. The start and end times of the visit shall be documented in the medical record along with the date of service."

So previous posts are correct in that the content does not seem to have been adequately documented.
 
I'd like to see how he incorporates the summary in his HPI. Is the summary clearly defined in the HPI or does he refer to the summary anywhere in the note along with total time spent with the patient, more than 50 percent of the face-to-face or floor time encounter was spent on C/CoC?

I haven't found any guidelines that dictate where the summary must be located, just that the record should describe the C/CoC and must be in sufficient detail to support the claim. Depending on the content, I may agree with your provider.
 
yes it does clearly state what he discussed or counselled with the patient. For example, in the HPI he will write, "Discussed diet options, new medication side effects, and labs in detail." Then, at the bottom of the note he will have, "face-to-face time with patient 20 min, more than half of the time was spent in counseling the patient."
 
Don't get stuck on WHERE he documents

Dont' get stuck on WHERE the physician documents, as long as the documentation fully meets the criterion. I've seen progress notes that are just one long paragraph ... chief complaint, HPI, ROS, history, exam, MDM, assessment, plan, etc all lumped into one big paragraph. Makes no difference. It's your job as a coder to decipher all the documentation and translate it into the appropriate code.

The key is whether the physician has documented:
1) total time spent Face-to-face with patient
2) Time spent in counseling/coordination of care (must be more than 50% of total time
3) Nature of counseling/coordination of care

If what is documented meets the above three elements, you can assign an E/M code based on time spent in counseling/coordination of care.

Hope that helps.
 
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