Wiki Coordination of Care - Inpatient

[nikki_coder]

Can anyone give me an example of what would fall under coordination of care for an inpatient (trying to bill based off of time)? I know the guidelines state the time doesn't have to be face-to-face and can occur on the floor/unit. But, does a face-to-face with the patient ever have to occur? Would reviewing patients chart, discussing patient with other providers and preparing orders be acceptable to bill an E/M service based on time without seeing the patient on that specific day?

 

[thomas7331]

The CPT book's section on E/M services under 'Definitions of Commonly Used Terms' gives a little more detail on this, saying that unit/floor time "includes the time present on the patient's hospital unit and at the bedside rendering services for that patient. This includes the time to establish and/or review the patient's chart, examine the patient, write notes, and communicate with other professionals and the patient's family." For inpatient, it does not have to be face to face time as it does for outpatient. Some organizations' internal guidelines may require that a face-to-face service be documented, but to my knowledge, the CMS and AMA guidelines do not specifically require this in order to bill an E&M for inpatients, but the services do have to take place on the patient's floor or unit - time spent off the unit is "not included in the time component described" in the E&M code definitions.