Wiki Billing based on Time


Monticello, MN
Best answers
I know that the lingo is supposed to state total time spent with patient of which ___ time was spent face to face..... Was wondering if this type of language would suffice for time. I am with a new employer and her patients are high maintenance patients that take up much time for a specific cause/counseling of care but the wording is not up to what I am used to seeing and want an opinion if it works?

"Greater than 30 minutes was spent in discussion and in education as it relates to disease process and
treatment plan"
From the 95/97 DG's

If the physician elects to report the level of service based on counseling

and/or coordination of care, the total length of time of the encounter (faceto-face
or floor time, as appropriate) should be documented and the
record should describe the counseling and/or activities to coordinate care.

In order for you to use Time-Based Billing, the statement of "I spent XXminutes with the patient with more than 50% used to counsel the patient on ............."

However the physician chooses to document that, it needs to have the minutes spent with the patient and/or caregiver and that more than 50% of the encounter was due to council and/or coordinate care. Without the "50% statement", it doesn't count.
Easy way to tell

There is an easy way to tell if the physician has documented the counseling time correctly or not. If you can make a percentage from the statement, then it's documented correctly. If you cannot come up with a percentage of time spent counseling, it's not documented. Correctly. If all that is documented is the total time, then a percentage cannot be determined such as "I spent 30 minutes with the patient...".