Wiki Time Based Coding

[sraines]

Do the key elements of an E&M have to be documented in order to bill based on time?

Example: Does a detailed history and exam, and low complexity medical decision making have to be documented for a 99203 in addition to the time based documentation in order to bill a higher level E&M...say 99204?

 

[sbicknell]

If the visit meets the time guideline, meaning 50% or more of the visit time was spent counseling and coordinating care, then the entire encounter can be coded based on time.

If the time guidelines are met, then the encounter E&M is not based on HPI, exam bullets or MDM.

For example, patient comes in with his wife and wants to talk about his upcoming surgery. There is no need for the physician to do an exam. He is not trying to evaluate or diagnose the patient. The CC is "patient has questions and concerns about planned surgery".

The nurse may have taken vitials but an exam in not needed. Physician documents what was discussed, ie the surgery and recovery, reasons for and answers all the questions from the patient and spouse.

Three important points about coding based on time:
1) counseling and coordination of care is time spent that is above and beyond the normal physician-patient commmunication. The physician is expected to talk with his patient, explain new meds etc

2) Time must be documented. Meaning the Physician must document total visit time and time spent C&C. "Spent 30 minutes discussing x, y an z. Total visit time was 45 minutes. Documenting both times supports the 50% guideline

3) There must be "sufficient detail" of the C&C time to support the time claimed. Meaning if the 30/45 minutes is being claimed there should be more than one line stating "discussed surgery"