Gastroenterology Coding Alert

Content, not just time, should be part of the medical record

If you want to be able to code based on time, make sure your physicians know to document the following:
 
1. Beginning and end time of the counseling and/or coordination of care. This information is vital for determining whether the counseling accounted for more than 50 percent of the visit.
 
2. Beginning and end time of the overall face-to-face visit. -I-ve actually gotten some of my physicians in the habit of writing the time they go into a room and writing the time they step out of the room -- and that often helps us prove that 50 percent of the visit or more was spent on counseling,- says Jaime Darling, CPC, with Graybill Medical Group in Escondido, Calif.
 
3. Details about the counseling session's content. Auditors will consider a claim fraudulent if you coded by time but your physician only documented -spent time counseling.- The physician must at least provide a summary of what the counseling or coordination of care involved, Darling says.