Wiki Time for Hosp DC

[tlwhlw]

Is there some place in Noridian Medicare billing where can I find that the actual time needs to be documented for a DC charge? I have a physician that is not documenting the time and since this is a time code, I need time!!

He is documenting that he arrived at 9am, but no end time or # of minutes. He will give me a DC charge stating he spent 90 minutes, but I see nothing documented in his written progress notes or dictated DC summary.

Same thing with Critical Care codes -- no time documented.
Thank you!!

 

[Dorothy Steed]

Discharge & critical care times

It is the responsibility of the physician to document time for discharge. 90 minutes seems outside the norm. Most physicians that I have asked have advised they can normally discharge within 30 minutes. An exception could be the need for an interpreter. Your physician should explain the rationale for needing 90 minutes.

Critical care must meet the required 30 minutes minimum, which is also the physician's responsibility to document.

 

[mitchellde]

Whether he can justify it or not if it is not in the progress note or DC summary then it is assume that less that the required minimum amount was spent and is then not chargeable. The required minimum is half of the stated time for the service.

 

[tlwhlw]

Thank you both for your help!! I have copied the front section of the CPT manual and given to the physician, made up a little notebook of info for him, so hopefully this will help him. He has been out of private practice for a few years and needs to refresh his memory on how to do all of this charting/dictating again! Thanks again!!!