Wiki Can a Time Statement be overriden?

[dtricia]

Must we use the time statement if it is obvious that the provider did not counsel, did not document how this time was spent? I am seeing visits with the correctly stated notation, but it is not apparent what was discussed. I want to challenge it and bill the level based on the HPI, exam and Assessment.
Tricia D

 

[thomas7331]

The CMS guidelines for use of time state that 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 (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care." I think it's pretty standard practice that if the content of the counseling is not documented then you would not code the level based on the time.

 

[dtricia]

Time based

I did find a reference from CMS :The physician may document time spent with the patient in conjunction with the medical decision making involved and the description of the coordination of care or counseling provided. Documentation must be sufficient to support the claim.'
From that I am assuming you cannot bill a 99215 if your note supports a 99213, no matter how much time you spent.
so I guess , yes the time statement is not rock solid. It is the medical necessity that we need to be looking out for.
Tricia