Wiki Dictation

[mjh1027]

Does anyone know if there is a code for time spent dictating reports??? I've come across CPT code 99358 but I don't know if dictating applies.

Please help!

 

[thomas7331]

Dictation/documentation is a required component of all services. There is no code for time spent dictating and no legitimate reason that I know of that would justify an extra charge or code for this.

 

[Orthocoderpgu]

After working with physicians for several years I know how easy it is for them to think that documentation is not that important, after all they treated the patient and did the work, so it's easy for them to document "bare bones" style or with EMR document everything under the sun because they are just going from box to box filling in everything they can find in the EMR. I would stress to your physician that their documentation in the EMR should not be any different than if they were writing everything out like they used to. Another thing to keep in mind is that insurance companies can get medical records faster and cheaper than in times past. And if the DOCUMENTATION does not support the codes billed, you are going to get a denial or they will take back their money. Insurance companies are doing this more and more since they have such easy access to records now. When doctors understand this, they look at documenting visits/surgeries as an important part of the process and not just "busy work" that really does not need to be done well.