Wiki Appropriate time documentation?

[ivygirl18@hotmail.com]

Hello,

A provider billed 99204 and is using time to meet the level. They document it as below:

40 or more minutes were spent in face to face contact with this patient with more than half of the time devoted to counseling regarding the problems identified

Should credit be given to meet 99204?? How do you know if they truly just spent the 40 minutes or actually spent 45?? Does the total time have to be at least 45 minutes??

The total face to face time for 99204 is 45. The total face to face time is used to make sure more than half of the time counseling and/or coordination of care.

I hope someone can help!

 

[Pathos]

Per CMS guidelines:

Documentation of an Encounter Dominated by Counseling and/or Coordination of Care When counseling and/or coordination of care dominates (more than 50 percent of) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting, floor/unit time in the hospital, or NF), time is considered the key or controlling factor to qualify for a particular level of E/M services. If the level of service is reported based on counseling and/or coordination of care, you should document the total length of time of the encounter and the record should describe the counseling and/or activities to coordinate care.

Because the provider did not specify "45 minutes" in the documentation, I would not accept the time documentation for a 99204. However, if there are enough E/M elements to meet History, Exam and MDM towards a 99204, and medical necessity is met, then 99204 should be appropriate. The statement "40 or more minutes" is too vague to account for additional time.

Hope this guides you somewhat!

 

[Cls1530]

I agree. I would not accept time based billing for that unless they meet the very minimum time for that code.

 

[ivygirl18@hotmail.com]

Thank you both for responding!