cbosi1
Contributor
Hi. I am wondering if anyone has seen any official guidance on how exactly to document time to justify coding? I have been researching; reading AMA guidelines, CMS guidelines and AAPC articles and forums. Per AMA and CMS, the definition of "Time" in the time-based coding is minimum time; not typical time. One of our providers believes that time should be documented to the exact minute, for example:
"I have personally spent 47 minutes total time today in preparation, patient care, and documentation for this visit, including the following: review of clinical lab tests; review of medical tests/procedures/services."
Currently, we are documenting based on the minimum amount of time for each code. For example:
"I have personally spent 40+ minutes today in preparation, patient care, and documentation for this visit, including the following: review of clinical lab tests; review of medical tests/procedures/services."
I couldn't find anything anywhere that says that documenting as "30+" or "40+" is incorrect. I haven't seen any official guidance that requires the actual times to be listed either. (10:15 - 11:02)
Any thoughts? Thanks in advance.
"I have personally spent 47 minutes total time today in preparation, patient care, and documentation for this visit, including the following: review of clinical lab tests; review of medical tests/procedures/services."
Currently, we are documenting based on the minimum amount of time for each code. For example:
"I have personally spent 40+ minutes today in preparation, patient care, and documentation for this visit, including the following: review of clinical lab tests; review of medical tests/procedures/services."
I couldn't find anything anywhere that says that documenting as "30+" or "40+" is incorrect. I haven't seen any official guidance that requires the actual times to be listed either. (10:15 - 11:02)
Any thoughts? Thanks in advance.