Wiki Documenting time when the documentation doesn't supports

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mskitaly09

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I have an OB provider that is using the same time statement(see below) for just about all of her claims. However, the documentation doesn't really supports 99214 but her time does. For this example not labs were done and the provider put MDM=M and the time is (30 mins).

My question is does the documentation has to support with or without the time statement? I did attend the Auditcon and I asked the same question and received 2 answers:
1.The instructor said go by what the provider documents that is what Medicare and insurance payers will go by
2. Someone else said if there is 50 mins of time but documentation is MDM low, its still 99215


Any feedback will help!

OB Example:
33 year old, G2P1001, 30w4d, presents to the clinic for a PNC visit. She admits to good FM. She denies LOF, VB, CTX, or abnormal discharge. No concerns at this time. Tdap vaccine given today.

PNC:
1. Marijuana/nicotine use: She admits to daily use of nicotine. She has decreased amount. She has stopped smoking marijuana. Discussed the risks to fetus and encouraged cessation.

2. Fetus: MaterniT21-negative, female, msAFP-negative, and anatomy scan-WNL.

3. Postpartum: Patient declined birth control postpartum. She plans on breastfeeding.

4. RTC in 2 weeks for PNC.

Assessment:
1. Use of nicotine during pregnancy - O99.330 (Primary)
2. Drug use complicating pregnancy, unspecified trimester - O99.320
3. Cannabis use, unspecified, uncomplicated - F12.90
4. Family history of heart murmur - Z82.49
5. 30 weeks gestation of pregnancy - Z3A.30

Plan:
Treatment:
1. Others
Notes: Total time reviewing chart, taking history, counseling, and documentation 30 minutes

MDM-M
 
Hello, I am not an expert and here are my thoughts:
1. per coding guidance ( what I remember) you choose whatever is higher: Time or leveling. in your case, the Time is higher.
2. if it's a trend that md always uses the same time with limited documentation, then I would talk to the MD expressing concern that in case of audits, it willl create an issue.
3. as for your case, the pt does have a problem of using nicotine and cannabis while pregnant (big danger to the fetus), so maybe MD had a lengthy conversation with the pt about it that took 30 min But it should be documented to justify 99214 to avoid red flags with the auditor. I would code based on time.
 
Problem/Red Flag #1 - using the exact same time statement and exact same amount of time in every note. Time should only be documented when the provider intends to code by time, not in every single note.
Problem/Red Flag #2 - what in this note supports that time statement, it is not specific and vague. Who took the time to review, take the history, and document? The provider, did ancillary staff do any of it, such as the history?
Problem/Red Flag #3 - Every single visit coded as a level 4 for every patient.

If time is documented, you would go by that if it is higher but this note is not good. And, if every single visit is the exact same, as stated above, you (or a manager, supervisor, etc.) needs to have a documentation improvement talk with the provider. Take 10-15 notes for E?M and audit them, are they all exactly the same? Or, take a few of this pt's notes, same?

 
Hi there, for official guidance on documenting time check the payer or MAC. I'm starting to see statements like this (from CGS):

Note: Time alone does not determine the level of service. Documentation must support the level of service billed.
Click to expand...

Of course we can look forward to many arguments about what statements like this mean, but it is a start. At any rate, I think that's not relevant in this particular scenario because I agree 110% that using the same statement for time (and time) is a huge problem.

On an audit the auditor will probably just deny the entire claim rather than downcode it. And then ask to see more charts.
 
natashalage said:
Hello, I am not an expert and here are my thoughts:
1. per coding guidance ( what I remember) you choose whatever is higher: Time or leveling. in your case, the Time is higher.
2. if it's a trend that md always uses the same time with limited documentation, then I would talk to the MD expressing concern that in case of audits, it willl create an issue.
3. as for your case, the pt does have a problem of using nicotine and cannabis while pregnant (big danger to the fetus), so maybe MD had a lengthy conversation with the pt about it that took 30 min But it should be documented to justify 99214 to avoid red flags with the auditor. I would code based on time.
Click to expand...

Thank you for your feedback!
 
amyjph said:
Problem/Red Flag #1 - using the exact same time statement and exact same amount of time in every note. Time should only be documented when the provider intends to code by time, not in every single note.
Problem/Red Flag #2 - what in this note supports that time statement, it is not specific and vague. Who took the time to review, take the history, and document? The provider, did ancillary staff do any of it, such as the history?
Problem/Red Flag #3 - Every single visit coded as a level 4 for every patient.

If time is documented, you would go by that if it is higher but this note is not good. And, if every single visit is the exact same, as stated above, you (or a manager, supervisor, etc.) needs to have a documentation improvement talk with the provider. Take 10-15 notes for E?M and audit them, are they all exactly the same? Or, take a few of this pt's notes, same?

Click to expand...


Thank you for your feedback!
 
jkyles said:
Hi there, for official guidance on documenting time check the payer or MAC. I'm starting to see statements like this (from CGS):



Of course we can look forward to many arguments about what statements like this mean, but it is a start. At any rate, I think that's not relevant in this particular scenario because I agree 110% that using the same statement for time (and time) is a huge problem.

On an audit the auditor will probably just deny the entire claim rather than downcode it. And then ask to see more charts.
Click to expand...


Thank you for your feedback!
 
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