billing based on time


New Haven, CT
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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)
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:) HI
Are you asking if it is okay not to do it or not to document it? I feel anything that is done should be documented, regardless of the impact it has on coding. The time it takes provider to obtain history, perform exam and counsel pt. is all part of the face-to-face time and you will want to add this in as well.


True Blue
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you don't have to document the hx, ex, mdm if you're billing based on time from a coding/billing perspective. you can simply state the time spent face to face (office/outpatient) or floor/unit time (inpatient) and that more than half of the encounter was spent counseling/coordinating care. to back up the time, you really only have to have a short sentence like above plus what was discussed (not necessarily involving the 3 key components)

however, always remember there is a clinical aspect they must meet. to protect themselves and inform other professionals they should always include more than just "30 minutes spent face to face counseling/coordinating care for patient's diabetes"
therefore, i always say document whatever you do...if time is a factor and allows higher coding, then great.