Wiki Time statement counseling &/or coordination of care

LuckyLily

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When coding on time, I am trying to determine if in a time statement the specific use of "counseling and/or coordination of care" needs to be used or can the doctor use the statement such as "discussing the diagnosis, treatment and management options."
 
We have told our providers to use this statement:

Greater than 50% of this face to face visit was spent in counseling or coordination of care. See note for issues discussed. Total time face to face:

then we tell them to fill in how much time and what issues were discussed.
 
No, they don't have to specifically use the words "counseling and/or coordinating care" verbatim, but they must state:
1) The total length of the encounter (face to face in the office setting or unit/floor time in the inpatient setting)
2) That greater than 50% of the face to face time was spent counseling the patient and/or proxy
3) The content of the discussion

It doesn't need to be a verbatim dialogue, but they should document the main point(s) of the discussion.
 
at our facility we have the same criteria that Mike indicates. It's important to make sure that the providers understand all three items. Sometimes they provide the total face to face time and never mention that over 50% of that time was spent in the counseling activity.
 
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