samyjm13
Guru
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.
Thanks
I hope all this makes sense, if not please ask.
Thanks