Wiki Documented time within office visit note

[LanaW]

There is an interesting discussion amoung the providers in our practice and they have turned to me to answer the question. Can they include the time in their office visit documentation that the MOA spent with the patient gathering info prior to the provider entering the room? I.E. MOA spends 15 minutes - provider spends 30 - can the provider document 45 minutes spent?
Thank you! Lana

 

[LLovett]

No they can't. Time based coding is for the face to face time spent by the provider, not their staff.

http://www.wpsmedicare.com/j8macpartb/resources/provider_types/2009_0817_emtimebased.shtml

Q1. When using time as the determining factor for inpatient evaluation and management (E/M) services, does greater than 50% of the time have to be spent in counseling/coordinating care (C/C), or is documenting total time spent on the unit/floor sufficient documentation?
A1. A provider may only use time in choosing the procedure code when spending more than 50% of the total face-to-face time of the visit in counseling / coordination of care. Documentation of the total time of the visit, the time spent in counseling/coordination of care and the nature of the counseling/coordination of care must be in the medical record.

If the medical record does not reflect the required documentation, then use the three key elements of history, exam, and medical decision-making to choose the procedure code.

In the office setting, document the total face-to-face time with the patient. In the inpatient setting, document the total face-to-face time with the patient or on the patient's floor or unit. The face-to-face time refers to time spent with the physician only. Time spent with other staff is not considered in selecting the appropriate level of service.


Hope this helps,

Laura, CPC, CPMA, CEMC

 

[LanaW]

Thank you!

That is what I thought - I just wanted to confirm BEFORE I answered the question. Thank you very much! Lana