Wiki Coding by time

[nhenderson]

I have a physician that wants to code a office visit by time however the patient has a chief complant "stiffness along the paraspinal muscles". The physician did a Expanded Problem Focused hx and exam but then spent 25 minutes with the patient so he wants to charge 99214 based on time instead of 99213 based on h&p. Can he charge based on time with a chief complaint?

 

[jackson7591]

reference posts

if you search the forums for "Time-based coding" you will find lots of useful posts.

In short, it is possible to bill based on time if the time was face-to-face, medically necessary, and well documented with respect to topics/issues discussed and their relevance to patient care. CMS documentation notes that start time and end time be included in the record.

Have to check to see the amount of time associated with 99214. If a provider wishes to bill based on time, the amount of time spent must match with the type of office visit with the same amount of associated time.

 

[btadlock1]

I have a physician that wants to code a office visit by time however the patient has a chief complant "stiffness along the paraspinal muscles". The physician did a Expanded Problem Focused hx and exam but then spent 25 minutes with the patient so he wants to charge 99214 based on time instead of 99213 based on h&p. Can he charge based on time with a chief complaint?

When counseling/coordination of care take up the bulk of the visit (meaning that they take up at least half of the total face-to-face time), the physician may select the CPT code based solely on time. The content of the counseling and/or coordination of care efforts must be documented, and the amount of time spent in counseling/CoC must be listed, as well. (That's not to say that the other 'key' components don't have to be documented; they do - they just don't control the code selection.) There should be a justifiable reason that your provider spent so much time with the patient - he just needs to explain what took so long, to be able to base his E/M code on it.

Per CMS, services, including E/M have to be medically reasonable or necessary, for a provider to bill them. He can't bump up a code to the next level on documentation elements, alone. It wouldn't be appropriate for a doctor to perform and bill a 99214, when the patient's condition warrants a lower level of service. CERT audits regularly target that kind of code selection, (especially with 99214, actually), and RAC's will downcode the claims and request a refund. And that would be the least of his troubles...

The point is, as a doctor, he's probably not wasting his time haplessly on a patient who doesn't need it; if he did a more thorough exam than what was needed to diagnose the problem, he should elaborate why he did so, in his notes. (Even a list of differntial diagnoses could suffice). The same goes for excessive counseling/CoC activities. It just has to show that they needed to do the work, and aren't trying to pad their payment, to support billing the higher code.