Wiki E/M level~ vs~ In & out times M.H

[Saddleup31]

My question has a couple layers. E/M levels with based on time statements I understand. BUT Now throw Mental health /behavioral health office visits that are billed Established visits 99213/4/5 with In and out times added at the end of the dictation. Documentation can support the 99213's and 99214's no problem. The concern is that I'm seeing documented IN and OUT times that are equaling ONLY 3, 4 , 6, 7 MINUTES ?!?!?!?! Does this IN AND OUT time that is documented time override the E/M. I'm struggling with this. ... thank you in advance.

 

[csperoni]

Whether mental health/behavioral health or any other specialty, if billing E/M 99201-99215, you may bill based on:
- history, exam and medical decision making (until 2021 changes take place)
*** OR ***
- time (if > 50% in counseling/coordination of care)

An efficient clinician can often perform a 99214 in far less than 25 minutes of face to face time.
The time does not override performing history, exam and MDM.

All that being said, consistent 99214 with only 3 minutes of time noted would certainly raise an eyebrow. I advise my physicians to document time when they are expecting to bill based on time.

 

[Saddleup31]

This is exactly my concern if/when there is an audit. That has always been the way I've known to do documentation forever. We do EMHR. I'm concerned that these documented times for IN and OUT will hurt us. I've been told that the IN and OUT has to be listed for the MH record and this will draw the attention of the auditor as a factor not justifying the level of service. And they will be pulled due to this fact as a big Red flag for a big pull. As a newer coder to BH, This isn't something I want to happen under my watch.

 

[LMBENHOFF]

I ask our providers to document duration of visits within their progress notes for the service. Our EHR defaults to appointment time and it is not a true representation of the time the provider spends with the patient.

I've included an attachment from CMS - "Medical Documentation for Behavioral Health" This is an excerpt from the guidance:

General Behavioral Health Medical Record Documentation Requirements

Behavioral Health services must meet specific requirements for reimbursement. Documented services must:

• Be complete, concise, and accurate, including the face-to-face time spent with the patient (for example, the
time spent to complete a psychosocial assessment, a treatment plan, or a discharge plan);

Also, it is possible that the "In and Out" times captured by your EHR may be based on the time when the provider opened the visit template to document the note and signed off. I advise having the provider document the duration of the visit within each Medical Record.