Coding with Time

Jacksonville , FL
Best answers
Can someone please tell me what is the correct VERBIAGE for time or point me in the right direction?

I have several doctors that are just stating time spent or at least 15 minutes.

Thank you

Domineack Brown

Local Chapter Officer
Seabrook, New Hampshire
Best answers
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 in outpatient/office) should be documented and the record should describe the counseling and/or activities to coordinate care.

Not only is it important to have the time documented appropriately but they have to describe the counseling and/or coordination of care to support the E/M based on time.This will also support the medical necessity of the time based visit on counseling/coordination of care which is still the overarching criteria of the visit.

Here are a couple of examples:

Time in ______ Time out _______ more that 50% of this visit was spent counseling the patient on ______ and/or coordinating _______ .

Of this 40 minute visit 25 minutes was spent reviewing management options. ( Again the body of the note needs to support this statement).

Greater than 50% of this visit was spent reviewing their management options with the patient. Options include _________.

I hope you find this helpful.
- Steph