Time Basing and Using Elements to Level a Visit

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I have a family medicine doctor who sets up her notes well - DOS, CC, all elements are documented. In addition to this, she ends every note with a time attestation basing the visit on time spent counseling and coordinating care. This is a quick text but she often can change her levels from a 4 to a 5 based on time. Can you insert both into a note and use the method that is most advantageous or does one method trump the other?
 

lmeredith

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I have a very similar question.... CC, all elements are documented, he coded a Level 3 but added this note "100% visit counseling and trying to load and read CD of spine x-ray (~15-20 min)" Should it have been coded as a Level 4?
 

Pathos

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I can answer both questions, although they are a bit different.

@amoneill118 - As long as the time documentation is correct, and medical necessity supports the code, then you can bill this service. Note that some payers will audit you if your provider routinely bill 992x5s for every visit, and your provider's note will have to weather these audits. When I audited E/Ms, I would allow the provider whatever gave them the highest level. So if time or E/M components allowed for a higher level, I would go with that route over the other.


@lmeredith - Remember the time thresholds here. A 99214 requires time documentation of at least 25 minutes. Your example is just shy of 5 minutes, and would be 99213 at best.

Hope this is helpful!

CMS E/M guidelines
 
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