Coding with Time

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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
 

stephanie.moore@wdhospital.com

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Local Chapter Officer
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Seabrook, New Hampshire
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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
 
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