Colliemom
Expert
When billing based on time, is it still necessary to document the HPI, exam and MDM? If you document the time, with a brief description of what was discussed with the patient in the counseling, does this meet the guidelines for billing that level?
We have a physician who takes a VERY long time to complete his notes. Since we do not bill for a visit until the note has been completed we are running into a timely filing issue. If we could simplify things for him, we might be able to get his billing submitted on time. One possible solution was to have him document a chief complaint and a brief description of what was done. For example "I spent 40 mintues with the patient, and more than 50% of the visit was spent in counseling the patient about the progression of her disease and possible treatment options." In your opinion, would this be enough documentation to bill a 99215? (if there is no documentation of an HPI, exam or MDM)
We have a physician who takes a VERY long time to complete his notes. Since we do not bill for a visit until the note has been completed we are running into a timely filing issue. If we could simplify things for him, we might be able to get his billing submitted on time. One possible solution was to have him document a chief complaint and a brief description of what was done. For example "I spent 40 mintues with the patient, and more than 50% of the visit was spent in counseling the patient about the progression of her disease and possible treatment options." In your opinion, would this be enough documentation to bill a 99215? (if there is no documentation of an HPI, exam or MDM)
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