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Simple time based question

smillar

New
Local Chapter Officer
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9
Location
Danville Pa
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When documenting time based visits, of course you need to have at least more then 50% of the total visit was spent on counseling and coordination of care. The question is, is it sufficient for staff to document "more then 50% of this encounter was spent on counseling and coordination of care for...." or do they need to specifically state the 2 times. "I spent a total of 50 minutes with this patient, 30 minutes were spent counseling and coordination of care for..." We cannot find anything listed specifically with this.

Thanks in advance...
 

dmaec

True Blue
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Hibbing, Minnesota
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hi smillar - they need to at least give total time spent with patient, and state that at least 50% of it was spent in couseling/coordinating and a bit of description of their services.
per CMS:
If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.
3 questions to ask are:
1) Does documentation reveal total time? (face-to-face in outpatient setting; unit/floor in inpatient setting)
2) Does documentation describe the content of counseling or coordinating care?
3) Does documentation reveal that more than half of the time was counseling or coordinating care?
If all answers are “yes”, you can select a level based on time.
*there you have my three pennies worth*;)
 
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