Documenting counseling time


Richmond, VA
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If a provider's billing sheet/record/charge ticket is a permanent part of the patient's medical record, can total visit time and counseling time be documented on the billing sheet instead of in the visit note? The provider feels it is tacky and morally wrong to document the time in the visit note that might be subpoenad. This is a plastic surgeon that performs a lot of breast reconstructions.
Thank you.
If you are coding by time, you have to document more than just the time you spend with the patient. You have to document total time spent with the patient, that at least 1/2 of the time was spent counseling the patient, and what the counseling was about. All of this information would need to be documented together.
Yes, more than 50% of total face to face visit time is spent in counseling. The physician documents total visit time and counseling time. The question is the location of this documentation. Does it have to be on the visit note or can it be on the billing sheet if the billing sheet is part of the medical record?
Thank you.
A Cook
I would say in the visit note but I can't find anything concrete saying it has to be in the visit note vs. the billing statement. I was looking in the CMS '97 guidelines, on pg 3, #7, it talks about the codes on the billing statement should be supported by the documentation in the medical record. That sounds to me like they are 2 separate items, and although your billing sheet is part of your medical record, the visit documentation should be complete with the time to support the billing sheet. You might want to take a look at the guidelines. You may interpret it differently than me. :confused: