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Wiki "TIME" based E/M

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mmunoz21

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Hi,

In auditing some medical records I have some doctors writing 45min or 80min spent with pt., of course to obtain the highes level E/M based on "TIME".. is it written anywhere (CMS, FSCO..ect) that the start time and end time has to be in the chart? I know it has to be written for prolonged services codes 99354-99358.
 
Counselling/Coordination of Care

To answer your direct question - no, the start/stop times do not have to be recorded BUT ..
You must record:
1. Total time spent face-to-face
2. Time spent on counseling/coordination of care
3. State what the C/C was about

e.g. I spent 70 minutes face-to-face with patient, 50 minutes of which was counseling about treatment options, risks and benefits of various options.

By the way ... I don't see where start/end time is needed for prolonged service either. Do you have a reference where you got this?
 
On the CMS website MLN#MM5972 prolonged services...

ThanksMLN Matters Number: MM5972
Related Change Request (CR) #: 5972
Related CR Release Date: April 11, 2008
Effective Date: July 1, 2008
Related CR Transmittal #: R1490CP
Implementation Date: July 7, 2008
Prolonged Services (Codes 99354 - 99359)


Thanks
 
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