jcochran
Guest
So,
We would like to start using the time based E/M billing, I have a quick question. Both the 1995 and 1997 CMS guidelines state that:
D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CARE
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.
I am unsure whether or not we would still need to meet the 3/3 or 2/3 guidelines as far as history, exam, MDM, etc... I have been unable to find a definitive answer anywhere.
As long as we document total face to face time with client in counseling and/or coordination of care, as well as medications/care discussed, what else do we need to document on each visit?
We would like to start using the time based E/M billing, I have a quick question. Both the 1995 and 1997 CMS guidelines state that:
D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CARE
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.
I am unsure whether or not we would still need to meet the 3/3 or 2/3 guidelines as far as history, exam, MDM, etc... I have been unable to find a definitive answer anywhere.
As long as we document total face to face time with client in counseling and/or coordination of care, as well as medications/care discussed, what else do we need to document on each visit?