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Wiki E&M service based on time for Peds

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Edithcha

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Hello,

I need some assistance in advising my pediatric provider on how to document better when counseling and/or coordination of care dominates the E/M visit. Does the provider need to document the "time-in and time-out" in the clinical record? Or is it enough by documenting that more than 50% of the visit was counseling?
Also, how does it differ from commercial insurances vs. Medicare/Medicaid?

Please help!
 
Hi

The key factors include history, physical examination, and medical decision making for the service. The level of selecting most E/M codes will be determined by these three key factors. However, time becomes the key factor when the counseling, coordination of care, or both account for more than 50% of the face-to-face time with the patient and/or family. When this situation occurs, it is necessary to enter the total duration of counseling and/or coordination of care into the clinical notes, as well as a description of the counseling and/or coordination of care that took place. - See more at: https://www.aap.org/en-us/professio...t-Coding-Strategies.aspx#sthash.JHvKJ13d.dpuf
 
Thank you Sherry for your help!
Do you know if the provider has to document the specific time spent counseling(i.e. from 10:00am to 10:20am)? or just saying 20minutes of the visit were spent counseling the patient about...? Please advise.

Thank you!!!!:)
 
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