99354 Face to Face time

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Hello out there!

Does anyone know if it's necessary for the provider to use the phrase "face to face" when using the 99354 in their dictation? Is this according to Medicare guidelines? Is there any information on the medicare website that constitutes this? One of my providers doesn't think so.

Thanks!

dscoder74
 
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Hi,
It is not necessary to include the phrase face-to-face with 99354, as the code itself is meaningful of the E and M type of service it prolongs.
 
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To make it "audit proof" use "face-to-face"

It's not an absolute requirement, but if you want "audit-proof" documentation I'd strongly recommend that the documentation includes the "face-to-face" qualifier. CPT is very clear on the meaning of face-to-face (look at the E/M guidelines - in CPT 2008 Professional edition, pages 4-5) and it is different in an office setting vs inpatient hospital setting.

I've always instructed my phsycians to use the phrase "face-to-face" or "direct patient care" when documenting for time-based services.

What's the mantra of documentation? "If it isn't documented, it didn't happen." Why leave room for doubt? It only takes a second to add the phrase, and it makes it crystal clear to the auditor what the service is.

Just my opinion ...

F Tessa Bartels, CPC, CPC-E/M
 
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