Wiki Documentation Smoking Cessation Counseling


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I am currently working with a group of physicians who are having a hard time understanding why the time spent doing smoking cessation counseling needs to be documented. The physicians feel that since the codes are time based, they know the amount of time they are spending and are selecting the correct code. From an auditing standpoint, I look at it that since it is a time based code and there is more than one, the documentation of time should be there for confirmation that the correct code was selected. When less than 3 minutes was spent it is considered part of the e/m therefore I see this as if the time is not documented I am going to assume they spent less than 3 minutes and cannot bill seperately. I do not see that this would be any different than an excision for example, if the margins are not documented we must bill the lowest level of excision removal because we cannot back up or confirm the size. It has always been my understanding that counseling is always time based therefore must be documented. What are everyone elses thoughts?
Also, I haven't even begun to advise them that the types of things counseled need to be documented, that is a whole other issue.

I agree with you also. Time needs to be documented in order to bill for smoking cessation or it's just a regular office visit. They also need to document if they prescribed anything like Chantix. I used to work in a large medical group and the smoking cessation issue was always a big one as far as chart notes showing time