• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki documentation for timed services

Create Wiki
H

hspaustat1

New
Messages
4
Location
San Antonio, TX
Best answers
0
I continually see deficient documentation for timed services. Instead of documenting time, "units" are recorded. For example: "Ultrasound (97035) was applied to the neck for one unit". This is also copy/pasted 30 times for each of the 30 visits, as is all the other treatments. Besides CPT guidance, Texas Licensing Board, requiring medical records support billing, and OIG audits reports, what other references are available to defend non-compliance. Or would you allow a one unit charge? And what if it were 2 units? I've seen up to 4 units documented instead of actual time. I generally do not accept this type of documentation, especially if over 1 unit and if there is no other supporting documentation reflecting the treatment, such as type of ultrasound, frequency of current for Electrical stimulation, etc.
 
As an auditor, I would not accept this. The code specifically says "minutes." Therefore, they need to document the minutes. An estimate is fine--they don't have to say "19 minutes," "26 minutes," "24 minutes and 4 seconds," etc.
 
You must log in or register to reply here.
Top