Wiki Depression Screening G0444

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KoBee

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can anyone clarify if providers are to be documenting time in their chart note on how long it took them to go over depression screening?

I noticed some of our providers do not document time but do mention the score.


Can someone help me?
 
KoBee said:
can anyone clarify if providers are to be documenting time in their chart note on how long it took them to go over depression screening?

I noticed some of our providers do not document time but do mention the score.


Can someone help me?
Click to expand...
The HCPCS code description includes the wording "5 to 15 minutes". It may seem to a provider to be a trivial detail, but if the time isn't documented, then you have nothing to support that the provider spent at least the 5 minutes required to meet the code description in order to be able to report the service.
 
thomas7331 said:
The HCPCS code description includes the wording "5 to 15 minutes". It may seem to a provider to be a trivial detail, but if the time isn't documented, then you have nothing to support that the provider spent at least the 5 minutes required to meet the code description in order to be able to report the service.
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Thank you, appreciate it
 
thomas7331 said:
The HCPCS code description includes the wording "5 to 15 minutes". It may seem to a provider to be a trivial detail, but if the time isn't documented, then you have nothing to support that the provider spent at least the 5 minutes required to meet the code description in order to be able to report the service.
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By any chance would you have any examples of some time statements i can reference to our providers to use, this could work great to add to our templates to better help them out.
 
Are they billing and E/M visit with it? If they are, the time for the e/m can't include the time spent going over the depression screening since it is a separately billable service. I would be careful of templated time statements. If the time is the exact same for every patient that can send red flags. Where I work we specifically have it in our policies that canned statements are not acceptable.
 
You may want to check with your local MAC, for instance "Palmetto GBA" states,
Documentation should include the following:
  • Depression in older adults may exist with other illnesses including cancer, arthritis, stroke, chronic lung disease and cardiovascular disease. What disease process is present that may be an underlying factor as it relates to depression?
  • What risk factors is the patient exhibiting? Do they feel sad or empty? Less interested in daily activities? Experiencing weight loss or gain when not dieting? Decreased ability to think or concentrate? Always tearful? Experiencing feelings of worthlessness and thoughts of death or suicide?
  • Describe the type of loss if any, they are experiencing (i.e., job status/financial difficulty, death of friends or loved ones, etc.)
  • The Patient Health Questionnaire is the most common screening tool used to identify risk. Be certain to include the tool used and the findings.
  • Plan of care (POC) includes patient education and support for patient self-management. POC also pays attention to patient preferences regarding counseling, medications and referrals to mental health professionals with or without continuing involvement by the patient’s primary care physician.
It does not indicate that documentation of time is required. I do not believe that G0444 is a time based code.
 
ksanthony said:
You may want to check with your local MAC, for instance "Palmetto GBA" states,
Documentation should include the following:
  • Depression in older adults may exist with other illnesses including cancer, arthritis, stroke, chronic lung disease and cardiovascular disease. What disease process is present that may be an underlying factor as it relates to depression?
  • What risk factors is the patient exhibiting? Do they feel sad or empty? Less interested in daily activities? Experiencing weight loss or gain when not dieting? Decreased ability to think or concentrate? Always tearful? Experiencing feelings of worthlessness and thoughts of death or suicide?
  • Describe the type of loss if any, they are experiencing (i.e., job status/financial difficulty, death of friends or loved ones, etc.)
  • The Patient Health Questionnaire is the most common screening tool used to identify risk. Be certain to include the tool used and the findings.
  • Plan of care (POC) includes patient education and support for patient self-management. POC also pays attention to patient preferences regarding counseling, medications and referrals to mental health professionals with or without continuing involvement by the patient’s primary care physician.
It does not indicate that documentation of time is required. I do not believe that G0444 is a time based code.
Click to expand...
Hi there-

Description of code has a time component
 
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