Wiki Need opinions on time documentation

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LLovett

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This is an established patient that they have made a decision to do surgery in this visit just pending the patients final decision.

Detailed history, problem focused exam, MDM of moderate. At the end of the note I have this

"Overall I spent about 40 minutes with Ms. Patient and her family this morning and the vast majority of this time was spent with medical decison making."

Another coder selected 99215. I'm not really comfortable with this due to the reference to MDM.

Insight is greatly appreciated.

Thanks

Laura, CPC, CPMA, CEMC
 
Counseling Coordination of Care

When you use time spent in counseling/coordination of care you do not need to meet ANY of the elements to determine the level of code.

40 minutes with an established patient and his/her family counts as a 99215.

F Tessa Bartels, CPC, CEMC
 
But he says the majority of the time was spent doing one of the elements that you don't count when coding based on time. This is my hang up on this one.

Laura, CPC, CPMA, CEMC
 
Coding Based on time

CODING BASED ON TIME:
You must document the total face-to-face time with the patient, and either the amount of time counseling/coordinating care, or that over 50% of the time was spent counseling/coordinating care.
Example: “I spent 30 minutes face to face with the patient and 20 minutes counseling/coordinating care”. Or “I spent 30 minutes face to face with the patient and over 50% of the time was spent counseling/coordinating care”. The note would also need to have in it what was actually discussed/counseled on.
 
I see what you are having issue with Laura. Stating that the 40 minutes was spent discussing MDM would not count in my book. The note must state a summarization of counseling, so "MDM" does not seem appropriate to me. Also, "vast majority" is not really stating greater than 50%...I think I would not count the time and go with the key components.
 
The way I interpreted the documentation

The way I interpreted the physician documentation statement was that s/he spent more than half the time discussing treatment options, risks/benefits. Had the physician stated just that, there would be no question that this was counseling/coordination of care.

I agree that the actual way this was stated is not clear, however.

F Tessa Bartels, CPC, CEMC
 
Lacking time specifics

With the lack of detail for amount of time spent counseling (I too don't like "vast majority"), I would use 99214 for the detailed hx and moderate MDM.
 
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