Wiki PFSH & Time

[TMB1965]

For a NP visit if the provider doesn't document a family history, but at the bottom of his note states he spent more than 30 minutes with the patient would that justify Coding a 99204 or 99205 Level. I have been given conflicting information regarding this, so any resources that would clearly explain this would be greatly appreciated.

Also if the provider puts reviewed- updated (9/1/2015) next to any of the PFSH wouldn't that be improper documentation?

 

[CodingKing]

Best reference would be the E&M guidelines. Page 48 talks about it.

https://www.cms.gov/outreach-and-ed...n/mlnedwebguide/downloads/97docguidelines.pdf

Time can only be used as a factor if more than 50% of the encounter was spent counseling and/or coordination of care. It must be well documented in the medical record. Merely stating spent xx min with patient is not enough.