Wiki Time spent reviewing chart

[torih@nwurology.com]

One of my physicians may spend about 20minutes prior to a patient visit reviewing old records. Is the only way to capture that time in the MDM table B? Or would he be able to bill using time if the visit consisted of more than 50% counseling and coordination of care?

Thank you,
Tori

 

[OCD_coder]

A provider can summarize records and receive two data points in the MDM section of the Audit Tool. This can make the difference between two-three levels (eg. 99213-99215) if documented adequately. Medicare likes the provider to identify the source of the records whether it is from a hospital or another provider; identify the name specifically in the summarization in the MDM section.

Time documentation is face-to-face with the patient, so if the provider is reviewing records in his office prior to seeing the patient this time cannot be counted for total time.