Wiki Time based coding

[lilleyea]

Is the following phrase sufficient to bill based on time?

"Total time spent was 45 minutes and more than 50% was in face-to-face discussion"

In the assessment and plan the doctor elaborates on what all is being discussed, however we have a question as to whether the word "discussion" is sufficient to bill for counseling. Also does the documentation have to state something like "total time of the face-to-face visit was 45 minutes with more than 50% spent in discussion/counseling". The question that is being brought up is does the above documentation reflect that the face-to-face visit was 45 minutes OR that the total time spent was 45 minutes charting, completing the record, etc?

Thank you for your help!

 

[ellzeycoding]

For time-based coding, more than 50% of the E/M encounter time must be spent counseling or coordinating care with the patient. This is provider time, not clinical staff time.

For documentation, you must document the total time spent on the entire E/M encounter and the total time spend doing the counseling/coordination of care and also exactly what was discussed.

Counseling/Coordinating care time does not include the time spent doing normal E/M activities (taking history, exam, and MDM).


For example:


"30/45 minutes spent counseling patient on various surgical treatment options for malignant melanoma, including risks and prognosis"

This tells me

45 minutes was spent on the entire E/M encounter
30 minutes (more than 50% of the 45 minutes) was spent counseling/coordinating care
What exactly was discussed


That's all you need!


By the way, the E/M code selection is based on the 45 minutes (entire E/M time), not the 30 minutes.

 

[thomas7331]

In CPT, under the E&M Services Guidelines at the beginning of the section, it defines counseling as
'a discussion with a patient and/or family concerning one or more of the following areas:
• Diagnostic results, impressions, and/or recommended diagnostic studies
• Prognosis
• Risks and benefits of management (treatment) options
• Instructions for management (treatment) and/or follow-up
• Importance of compliance with chosen management (treatment) options
• Risk factor reduction
• Patient and family education'
So I think if your documentation supports discussion of one or more these items, it should be fine, I wouldn't be too concerned that the provider didn't specifically say that the discussion was 'counseling'. But you might consider having your provider create a template for their time-based visits that is worded a little more closely to payer audit requirements just to prevent any confusion on it.

 

[lilleyea]

Thank you both so much! I am in total agreement regarding counseling being defined as a discussion. My other question is does the documentation have to state "total face-to-face time spent was 45 minutes..."? What I am getting push back on is that this statement does not clearly reflect that the physician was present face-to-face with the patient for 45 minutes.

Thanks again!

 

[CodingKing]

If i were auditing this i would not give credit for "discussion". what was discussed? patients holiday plans? how the kids are doing in school? How the local football team is doing? Its way too vague.

 

[lilleyea]

In the assessment and plan the doctor elaborates on what all is being discussed. My question is regarding the phrasing of the statement "Total time spent was 45 minutes and more than 50% was in face-to-face discussion". This is what I am being told:

For her time documentation to be appropriate, she needs to indicate that the total visit time was spent face-to-face. Based on what she has in her note right now, it would appear that only the discussion portion or the 50% was face-to-face rather than the whole visit. If she had left the face-to-face wording out of the last part, we could have allowed credit. (E.g. Total time spent 45 minutes and more than 50% was spent in discussion).

Opinions on this???