Time Coding Example


Appling, GA
Best answers
We have a few doctors who will dictate a note and at the bottom state: Spent 35 minutes with the patient.

In order for us to code by time only, doesnt he need to state how long he spent with the patient and how much of that time was spent discussing coordination of care?

Here is an example below.


The patient is a 57-year-old woman who was admitted to the hospital the 1st week of May of 2012 because of chest pain and shortness of breath. Evaluation revealed a 2.7-cm mass in the left upper lobe and an 8.5-cm mediastinal mass. Percutaneous needle biopsy via CT guidance revealed small cell carcinoma consistent with a lung primary. The patient had smoked for many years. Staging evaluation revealed a negative CT scan of the abdomen, negative brain scan, and a negative bone scan. The patient returns today for followup. She states she is breathing better and her chest pain has improved.

Vital Signs: Performed on May 07, 2012 11:33
Height 60.30 in Weight 174.20 lbs
BSA (derived) 1.83 sq.m BMI 33.68 (HIGH)
Temperature 98.50 F Respiration 18.00 /min
BP 122/76 Pulse 76.00 /min
Pulse Oximetry (O2 Sat) 93.00 %(LOW) Pain Assessment 0.00

Vital signs are stable.

Evaluation revealed an unremarkable CBC. CMP is pending.

The patient has small cell carcinoma of the lung, limited stage disease.

I have recommended concurrent chemoradiation. She will return tomorrow for initiation of chemotherapy with cisplatin and VP-16. She will also receive Neulasta prophylactically. I have arranged for her to have a radiation therapy appointment this afternoon, so she should be able to start radiation therapy as soon as possible. I have gone over all the potential benefits and side effects of therapy with the patient and family. She understands and agrees to treatment.

I spent about 1 hour with the patient on this visit.
If your doctor wants to bill based on time only and not on the E/M element requirements, then yes he would need to document the total time he spent with the patient along with a statement that he spent more than 50% of that time in counseling.

We have our doctors include a statement such as - "counseling and coordintating care was greater than 50% of the visit, total time spent was 60 minutes." Then they MUST also document the content of what was discussed during that time.

We encourage our doctors to only put the time spent with the patient only if they are billing on time and to only use this method if absolutely necessary as in an audit if the provider only bills on time there could be an issue as to how many patient's they had seen during their scheduled hours - i.e. if they document they spent 1 hour with each patient and billed that way, they would only be seeing 7-8 patients a day and if the schedule shows 15 patients this would not add up! Audit red flag!!
I agree with Jodi!

When I do our audits, if that statement of:

"Total time spent was xx minutes, with >50% of the visit in direct face-to-face counseling and coordination of care with the patient discussing/treating/planning, etc...."

is missing then we do not count that visit as being Time-based.
The office is face-to-face and it seems that is a missing piece for the doctors.

They do not have to state it exactly, '"Total time spent was xx minutes, with >50% of the visit in direct face-to-face counseling and coordination of care with the patient discussing/treating/planning, etc...."

They can say "I spent 40 minutes of this 60 minute encounter with the patient in coordinating care for her breast cancer surgeries, chemotherapy and counseling her on the emotional effects of ...."

I have a doctor who likes to say, "I spent 10 minutes collecting/updating history and performing an exam and the remainder of the 50 minute encounter was in counseling and coordinating the treatment plan for .... as described below." Then he lays out the plan of care in another paragraph.

As long as the math is >50% in ccc.

They need to document that the time is with the patient not in their office calling other providers or doing research or reviewing medical records-- unless they are doing those things with the patient present (never seen that happen).
They must describe the plan.