Wiki e/m levels based on time


Meridian, ID
Best answers
I have a doctor who is not getting the level he wants with what he is documenting (he is new to our facility) so he has started using time based to get the higher levels. His documentation is complete and supports the E/M level, but then puts the time face-to-face is over 50% in counsel/coordinating care, so he can get a higher level. Know...I know that the documentation needs to support that extra time spent...sometimes he does extra documentation in there, but sometimes I don't feel like he has enough to support the time based. How does one determine "what is enough documentation." It surely can't be a guessing game. This all makes me very nervous coding this doctor.

I hope all this makes sense, if not please ask.

Your doctor should not be doing time based visits just to get the higher levels. First of all this raises a red flag with insurances and if he is audited and they find out he is doing time based all or most of the time without proper documentation your practice could be in trouble. Unless the time is actually warranted for example if he spends 45 mins with a patient even though the level is only lets say a 99202 and he documents that he counselled them on lets say proper diabetes care 50% of the time ,that's ok. Otherwise I would just code the levels as you normally would
Does he expalin what he talks to the patient about? just saying counseling/coordination of care is not enough he needs to explain what he counsled the patient about.