Wiki Documenting Time

[KoBee]

Hello.

Would like some reassurance or review of the following time statement from one of our providers. I think they are documenting the time statement really well, but we have a concern with the following in the time statement when mentioning the activities " ordering tests/new meds or refilling meds if indicated". Provider has a set template but never changes the wording of that statement, which is probably why they put " if indicated" so they don't have to keep updating whether they have new orders or not, or new meds or not or refilling meds or not.

would this be, okay? or can it flag an audit?

This is the complete time statement example" A total of 45 minutes was spent on this visit, with 20 minutes spent reviewing previous notes, counseling the patient on their chronic illnesses, ordering tests/new meds or refilling meds if indicated, and documenting the findings in the note. An additional 5 minutes was spent on counseling on healthy lifestyle choices. "

Appreciate any feedback.

 

[jkyles]

This is the complete time statement example" A total of 45 minutes was spent on this visit, with 20 minutes spent reviewing previous notes, counseling the patient on their chronic illnesses, ordering tests/new meds or refilling meds if indicated, and documenting the findings in the note. An additional 5 minutes was spent on counseling on healthy lifestyle choices. "

Hi there, first, let's acknowledge that there has been very little (if any) official guidance on how time should be documented.

For this template my first concern is that by mentioning total time it creates a difference between total time and specified time. Here the provider says they spent of total of 45 minutes but they only account for 25 minutes. It is as safe bet a reviewer will have questions about that apparently missing 20 minutes.

At any rate, my recommendation would be document what they did and give the total time. (Making sure it is clear they're only counting time on the date of the encounter.)

An alternative would be check boxes for different activities and an open text box for anything else, and give the total time.

But attempting to give the time for each activity (or some activities) related to the encounter plus total time makes more work for the provider.

As for that blanket statement - I agree that if a reviewer sees the same statement in every chart they're going assume that is just copy/paste.

 

[Claimpower12]

According to AMA guidelines, when billing based on time, the total time spent by the physician or other qualified health professional includes a range of activities such as preparation, history review, examination, counseling, ordering, documentation, care coordination, and communication with other professionals, provided these are not separately reported. While these components are clearly outlined, the guidelines do not mandate a detailed breakdown of how much time was spent on each individual activity. Therefore, from an auditing perspective, it is acceptable for providers to document the total time spent along with a concise summary of the services performed. A statement such as “A total of 45 minutes was spent on this encounter, including discussion of medical history, medication reconciliation, review of systems, lab orders/Lab results discussion, and care planning,” is sufficient. Including start and end times—when available from the scheduler or EHR—can further reinforce the validity of the documentation without appearing as a generic or blanket statement.