Wiki Documentation for time

[anwara]

Hello!
I need help with this.
For the new time coding: can providers document accounts with E&M codes time ranges without selecting specific time? or they have to document time within the range.

Example:
I have seen this patient for 10-19 minutes during todays encounter....?

 

[SharonCollachi]

I have nothing official to back me up, but I would give my boss the stink-eye if he tried to do that. That is not a documentation of time.

 

[Cheezum51]

I believe it would be best to document a specific number of minutes for the visit versus a range.

Tom Cheezum, OD, CPC, COPC

 

[amcook31]

I would also agree that it requires the specific number of minutes spent. It's also my understanding that the provider needs to document how that time was spent. Such as reviewing tests, ordering medications, communicating with other providers, etc.

 

[anwara]

Thank you all.

 

[SharonCollachi]

It's also my understanding that the provider needs to document how that time was spent. Such as reviewing tests, ordering medications, communicating with other providers, etc.

I have not seen that from anyplace official, and absent that official documentation, my response is "no way." The whole point of the new system was to reduce the amount of documentation needed, not INCREASE it. If we have to document the individual minutes, that is contrary to the new system.

 

[Cheezum51]

All you have to document is the total time. You do not have to break it down into time spent on each individual task.

Something like: "Total face to face and non face to face time for this exam wa 20 minutes" should cover it.

Tom Cheezum, OD, CPC, COPC

 

[Jessim929]

Total time spent is to be documented, not a range. And breakdowns are not necessary.