Wiki Time factor and exam element in E/M

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himanib

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The patient was seen with comprehensive Hx, a description of assessment and plan was described in detail. The provider says he spent 75% of the total time in C/CC. Time factor can be a key to coding in this scenario.

Now, the question is the provider has not entered any exam elements at all. According to him, considering the time factor, exam does not need to be there to code. I think the exam has to be there to come up with the assessment and plan. Any feedback? I looked up on CMS website, but could not find anything specific for this scenario.
 
Did he document total time spent? Time can be the controlling factor in other than emergency encounters as long as total face to face tme with the physician is documented in the physician encounter note, not just saying 75%.
 
joseph.bedford said:
The only time that you considered time in E/M is emergencies.
Click to expand...

To be perfectly blunt- this is just not true, Joe.

In fact, you CANNOT use time as a factor in determining E/M level in the emergency department. In most other inpatient or outpatient E/M services, you are absolutely allowed to use time as the controlling factor when counseling/coordination of care dominates (more than 50%) the encounter.

The 3 key things that an acceptable "time statement" must convey are:
  • The total length of the encounter (not simply "we had a lengthy discussion" or "I spent much of my morning with this patient")
  • That greater than half of the encounter was spent counseling/coordinating care (this can either be done by simply stating ">50% spent counseling the patient" or by stating something like "15 minutes of this 25 minute encounter were spent counseling regarding.....")
  • The content of the discussion. This is usually eveident from the assessment/plan portion of the note, but if note I always advise the provider to list the topics that were discussed. It does not need to be a verbatim dialogue, but it should answer the question "what was discussed?"

Remember the reason those time conventions are there in the first place. When the provider or coder selects a level of service, he/she is attempting to accurately reflect the resources expended in that encounter. The resources could be higher in terms of cognitive labor and complexity for a 15-minute encounter with a patient who has multiple chronic problems, or it may higher in terms of time spent with a patient who has a low complexity issue but the encounter takes longer than usual because the patient has a lot of questions, is argumentative, or is emotional during the encounter. Whichever aspect (complexity or time) is the most resource intensive, that should drive code selection. The important thing is that whichever way you are selecting the level of service, your documentation must support that.

Getting back to the original question - if the level of service is determined by time spent counseling (in your example it was 75% counseling) then there is no requirement that I know of that a physical exam must be documented. The level of history, exam, and medical decision making complexity are not considered. What must be documented are the 3 bullets I listed above.
 
Thank you, all! Mike, good to know that the time (contributing factor) requires only these three elements specified in guidelines for that particular contributing factor to be considered.
 
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