Wiki Physical with a E&M based on time?

[drochelle37]

I have some pediatric physicians who do regular physicals but also send a great deal of time consulting about ADHA and other behavioral health disorders. These are hard to document without using a time statement. Can a time statement be used with a physical if is specifically states that time is over and above the time spent doing the physical?

 

[mitchellde]

If you are referring to the preventive levels, these cannot be upcoded or have prolonged time appended.

 

[drochelle37]

I was referring to adding an E&M with a modifier 25 but instead of meeting the HPI, exam and MDM requirements using time instead since it is a mental health issue and hard to document.

Thanks!
Dana CPC

 

[FTessaBartels]

Problem focused established patient

So what you would be coding would be a problem-focused established patient exam, based on time spent in counseling/coordination of care.

For example: I spent 15 minutes with Johnny & his mother discussing Johnny's ADHD, medication options, behavior modification, and issues with schooling. 100% of this problem focused visit was spent in counseling/coordination of care.

Ideally this would be documented as a separate note, not just buried in the report of the preventive exam.

You would then code 99213-25 for this portion of the total visit.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[drochelle37]

Thank you for your reply.

Dana