Wiki Time Based Visit

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deyoung

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Hi, I am new to E/M coding and trying to understand how to document a time based visit (counseling &/or coordination of care >50%) for Psychiatry.

My understanding, is they only have to document:
1. Total time of visit
2. State that visit consisted of >50% counseling and/or coordination of care.
3. Briefly describe counseling &/or coordination of care topics.

They don't have to include Hx, Exam, & MDM documentation. So, it may be a short note. Is this correct? It just seems to simple to me. Thanks for your input!
 
You've got it~

When you devote more than 50 percent of your face-to-face time with the patient to counseling or coordinating care, time may be considered the key or controlling factor to qualify for a particular level of E/M service.

An example of documentation would be:

"30 minutes of face to face was provided;more than 50% of which was devoted to counceling" (also include what was discussed)

I also encourage my providers to document the "beginning and ending" time. Some do this better than others.

Rebecca:)
 
Last edited:
Teaching Physician

I am not clear on what a teaching physician (TP) has to document for a time based code in addition to the residents note. This is my understanding:

1. TP performed the service or was physically present during the key or critical portions of the service when performed by the resident.

2. Participation of the TP in the management of the patient.

(Would the above 2 items be the "describe counseling and/or coordination of care" criteria?)

3. Time TP was present (I am not sure if this is required in the note. I know they can only bill for the time they are actually present and not combine their time with the residents. I am thinking the only way to know this is to ask them to document their time?).

Thanks!!!
 
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