Wiki Inpatient Time Based Billing

[BLP]

What documentation is needed? The subject is inpatient billing by time documentation requirements. At work we are recently told that more than 50% counseling does not have to be documented, that it is inferred in the inpatient setting, that the provider only needs to note his total floor/unit time. My research shows that inpatient E/M still requires the the three time elements listed on the 1995 score sheet. This is an inpatient specialist not a hospitalist, in the year 2022. Thank you. Your input is much appreciated.

 

[csperoni]

Nothing is "inferred". The documentation must state >50% of time spent in counseling or coordination of care to bill by time in the inpatient setting. It does not need to list specific times, but the provider must put in the >50% statement, or indicated in another way.
For example: Spent 35 minutes face to face with patient, then 45 minutes on the floor coordinating care with patient's cardiologist, gastroenterologist and hospitalist. You can clearly see 80 total minutes and 45 of them coordination of care which is >50%. In my hospital's EMR system, there's a radio button the provider can use with the >50% statement and then provider just needs to indicate total floor/unit time.
Absent the documentation of >50% time counseling/coordination of care, you must code on history, exam & MDM using 1995 or 1997.

 

[BLP]

Nothing is "inferred". The documentation must state >50% of time spent in counseling or coordination of care to bill by time in the inpatient setting. It does not need to list specific times, but the provider must put in the >50% statement, or indicated in another way.
For example: Spent 35 minutes face to face with patient, then 45 minutes on the floor coordinating care with patient's cardiologist, gastroenterologist and hospitalist. You can clearly see 80 total minutes and 45 of them coordination of care which is >50%. In my hospital's EMR system, there's a radio button the provider can use with the >50% statement and then provider just needs to indicate total floor/unit time.
Absent the documentation of >50% time counseling/coordination of care, you must code on history, exam & MDM using 1995 or 1997.

Thank you!