99354 Extended time

[AHudyma]

I am confused if actual time in/time out needs to be documented, or does provider just have to say additional 30 minutes was spent with patient discussing labs, etc.

Any help to clear up my confusion would be great!

 

[CodingKing]

Per CMS, The start and end times of the visit shall be documented in the medical record along with the date of service.

 

[AHudyma]

Thank you!

 

[cerullhon]

Prolonged Care

Is there an example of how prolonged care for In Patient should be documented? Also, what happens when one provider sees a patient, then another rounds on the same patient, same day. Can we bill prolonged care under the first provider? AND one more question, I've heard Prolonged Care is on the OIG's radar.....anyone have any experience with that?

Thank you.