Wiki time coding

[samyjm13]

I have ask this question before on time coding and how much documentation should there actually be to warrent the time given. For example: The provider did a Subjective, no Objective, Impression/Plan. At the end he states: "Extensive time was spent counseling patient on the etiology of her overactive bladder." 45 minutes spent with patient, greater than 50% of the time was spent face-to- face in discussion and coordination of care.

I don't feel that the one sentence is enough to warrent 45 minutes. I want to send this back to the provider for more documentation.

Does anybody have any comments on this gray area of time spent coding.

Please help!!!

 

[ollielooya]

Hello, I've seen you inquire about this before and can understand your hestitation, but basically if the visit supports a time based visit, and the documentation supports the criteria demanded, then a well written one line statement is INDEED enough to code based on time alone. IMO and from my studies the statements "Extensive time was spent counseling patient on the etiology of her overactive bladder, and 45 minutes spent with patient, greater than 50% of the time was spent face to face in (and/or direct) discussion and coordination of care.

I must ask, what is it you are "expecting to see from the doctor' and what is making you want to send it back to the provider for more documentation? Just curious.

Sometimes it's just hard to let the mindset from regular EM coding rest when you're dealing with scenarios that might call for the different approach of time based coding. I know it was and is still hard for me to switch gears at time.

Hope others will comment as this is a good thread.
---Suzanne E. Byrum CPC

 

[samyjm13]

Suzanne,

Thanks for your response, it helped me put some thoughts in perspective.
The answer to your question, I am not sure, maybe my own gray area of the whole time spent coding thing. But again, you have helped.

Thanks
Jeanne,CPC

 

[hawkinsj]

I agree, perfect response!