90806

soprano

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In the CPT book under 90806 it says "approximately 45 to 50 minutes face-to-face with patient." Does this verbage need to be documented in order to bill this code? If so, is there somewhere that officially states this?

Currently none of my providers document either time or the phrase "face to face with patient." I think that this should be somewhere in the notes but I want something to show them that it says they should be doing this for each patient.
 

RebeccaWoodward*

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In the CPT book under 90806 it says "approximately 45 to 50 minutes face-to-face with patient." Does this verbage need to be documented in order to bill this code? If so, is there somewhere that officially states this?

Currently none of my providers document either time or the phrase "face to face with patient." I think that this should be somewhere in the notes but I want something to show them that it says they should be doing this for each patient.
Page 464 of the AMA 2012 CPT book..."the face-to-face time spent with the patient"...

This quotation can be found under the heading "Psychiatric Therapeutic Procedures"; 5th paragraph.
 

soprano

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Thank you for the reference. I read the 5th paragrapgh on pg 464 of the AMA CPT 2012. It says that the appropriate code is based on the face-to-face time spent with the patient. It does not, however, say that this needs to be documented. My provider says that she has never documented this and she doesn't see where it says she is required to.

I'm looking for something that specifically says that time spent face-to-face with the patient MUST be documented. Is there something like this out there?
 

RebeccaWoodward*

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Thank you for the reference. I read the 5th paragrapgh on pg 464 of the AMA CPT 2012. It says that the appropriate code is based on the face-to-face time spent with the patient. It does not, however, say that this needs to be documented. My provider says that she has never documented this and she doesn't see where it says she is required to.

I'm looking for something that specifically says that time spent face-to-face with the patient MUST be documented. Is there something like this out there?
Yes...CPT Assistant March 2010.

Excerpt:

"Code selection is based on the documented type of psychotherapy service, the place of service, the face-to-face time spent with the patient, and whether evaluation and management (E/M) services are provided on the same date of service as the psychotherapy."

If your provider spent 45-50 minutes with the patient and not documented, the carrier can reduce the visit to 90804 since the documentation doesn't support 90806.
 
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