Wiki Billing Based on Time

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angbriscoe

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I am looking for guidance on a provider who is billing everything based on time and has a higher utilization of level 99215s. His documentation based on MDM only supports the 99214 level but his time documentation supports the 99215. We have looked at his time for the day based on CMS time per procedure and it is about 8- 11 hours per day total. We know Medical Necessity is still required however if the provider documents they spent 50 minutes with the patient reviewing prior records, documenting in the chart, etc. it is hard to use medical necessity as to why they can’t be billing all based on time. This is a PCP Family Medicine Provider. Does anyone have any advice on how we could handle this type of situation?
 
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This is a good question and will hopefully be an interesting discussion. I think we touched on this in another thread about time based.
What is the specialty of the provider?
The cumulative time per day you found is not "impossible time"? Meaning, the schedule for the day and the amount of time claimed are not off? Are the notes unique and specific to the patient being seen or is it just a cloned statement every time?
I think it would require more digging and possibly reviewing multiple months/days.
Even if they "can" do it, all of those 99215s will trigger an audit for sure. Especially if the provider is out of the bell curve for that specialty and geographic area/peers.
 
amyjph said:
This is a good question and will hopefully be an interesting discussion. I think we touched on this in another thread about time based.
What is the specialty of the provider?
The cumulative time per day you found is not "impossible time"? Meaning, the schedule for the day and the amount of time claimed are not off? Are the notes unique and specific to the patient being seen or is it just a cloned statement every time?
I think it would require more digging and possibly reviewing multiple months/days.
Even if they "can" do it, all of those 99215s will trigger an audit for sure. Especially if the provider is out of the bell curve for that specialty and geographic area/peers.
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It is the PCP Family Medicine Provider. The time is not impossible for the day and the notes are pretty similar with a bit of variation in the time such as 40 and 44 minutes in some notes.
 
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