Wiki Time Based Coding


Troy, MT
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When coding based on time, do you need any HPI, Exam, MDM? Or can it be as simple as saying out of a 45 minute visit 40 minutes was spent counsling Pt about tx options, tx options consit of what ever they are, current HA and what ever else the Dr and Pt talk about. Thank you
time based documentation

As long as you can answer the following 3 questions yes, then you can billed based on time:
1 Does documentation reveal total time?
2. Does documentation describe the content of counseling or coordination of care?
3. Does documentation reveal hat more than 50% of the time was counseling or coordinating care?

Documentation may refer to: prognosis, defferntial diagnois, risks, benefits of treatment, instructions, compliance, risk reduction, etc.

When you use time as the driving factor it doesn't matter what is in the HPI, Exam and MDM.

Hope this helps.
Yes that is helpfull, what doesn't help is the fact that it depends on who you ask the question to, I have heard and read that you also need the MDM, HPI and so on with the time, and then I have also heard and read what you say as well. So what is a coder to do? Is it better to then have at last the HPI,and ROS with the documented time so that you know every thing is there and your chart note can support that.
In reviewing the documentation guidelines on the CMS website, nethier 95 or 97 guildelines state that you need HPI and ROS. Wendy is right on the money. If you hear or read differently send them back to the guidlelines.

In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.

DG: If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.
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If it helps any, that criteria is from MGMA's Audit worksheet. It is also the same time documentation criteria on the Mountain State (HighMark Blus Cross Blue Sheild) Audit worksheet.
Does that help you out any?