Wiki Is time spent with patient a reason to code higher?

[liloe517]

Here is an example... I have a provider that is constantly billing level 5 office visits, both new and established. When you read her notes you would code it as a level 4 possibly even a level 3 but at the end of the note she always states the amount of time spent with the patient. i.e Counseled greater than 45 minutes or counseled greater than 60 minutes. She is a breast surgeon and she indicates at every visit that she is reviewing self breast exam and imaging even if she saw the patient the previous week. In reading the notes that she has it doesn't seem like she would be spending that much time with the patient going over their problem but since she is documenting the time do I have to code for it?

 

[CodingKing]

The time of the visit must be documented. It must specify how much of the time was spend doing counseling/care coordination. It must also detail what counseling and care coordination was done. You are right it wouldn't take that long to training of self breast exam. reviewing x-rays doesn't fall under care coordination.