I have a provider that submits level 4 and 5 E/M codes on nearly every claim stating that he spent the relevant amount of time with the patient to support that level code. He adds the saying that more then 50% of his time was spent counseling or coordinating care for the patient. The rest of his documentation in the medical record is very vague. I want to deny the claims because to me the medical record does not meet the level of MDM to support that code and I don't believe that the "Medical Necessity" is met. Example, that patient came to follow-up on blood work test results, the provider states he spent 50 mins discussing the blood work but the lab reports are not included in the documentation to verify extensive findings that would warrant a 50 min review. How can I get around the documented time? Can I deny base on med nec.? Should the record show what elements of the exam equal up to the total time documented? HELP!
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki E/M Time Coding without Supporting Documentation
- Thread starter ebonih9@gmail.com
- Start date
jkyles
True Blue
- Messages
- 937
- Best answers
- 1
Hi there, two things:
1. The 50% of counseling/coordination of care guideline hasn't applied to office visits since 2021. It was eliminated for all other level-based visits (hospital, home, etc) this year. Please make sure your provider is using the current CPT manual.
2. Neither CPT nor Medicare have issued documentation requirements for time-based visits. CMS has issued language that essentially means an auditor can decide whether the documentation is complete. However, according to your example the provider documented that they spent 50 minutes on a service that counts toward time, so that would be complete.
1. The 50% of counseling/coordination of care guideline hasn't applied to office visits since 2021. It was eliminated for all other level-based visits (hospital, home, etc) this year. Please make sure your provider is using the current CPT manual.
2. Neither CPT nor Medicare have issued documentation requirements for time-based visits. CMS has issued language that essentially means an auditor can decide whether the documentation is complete. However, according to your example the provider documented that they spent 50 minutes on a service that counts toward time, so that would be complete.
Last edited:
julieordway
Networker
Sounds like your provider might need some coding education on time coding. The "more than 50% of time spent on counseling..." rule is no longer in effect. You'll want to update the verbiage on your templates. CPT did away with that in 2021 I believe. The new rules state a practitioner may count all time spent with the patient on the date of service, not just face-to-face time. Counseling doesn't need to dominate the visit and your provider doesn't need to meet both MDM and time. In addition to the face-to-face time, your provider can also count the following:
He could be setting up themselves for an audit.
- preparing to see the patient (eg, review of tests)
- obtaining and/or reviewing separately obtained history
- performing a medically appropriate examination and/or evaluation
- counseling and educating the patient/family/caregiver
- ordering medications, tests, or procedures
- referring and communicating with other health care professionals (when not separately reported
- documenting clinical information in the electronic or other health record
- independently interpreting results (not separately reported) and communicating results to thepatient/ family/caregiver
- care coordination (not separately reported)
He could be setting up themselves for an audit.