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Wiki Time Documentation

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syounger

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As part of a retrospective review, the services requiring time documentation, what is the best practice when the time IS NOT documented? Are your auditors recommending coding to the lowest service or non-billable service? (99331-99443)
 
If the lowest service indicates 5-10 minutes of time and time is not documented, then it is non-billable.
The service could easily have been less than 5 minutes if not documented.
If the lowest service description said "up to 10 minutes", then I would feel comfortable using that lowest level.
In your question above, I am assuming a typo and you meant 99441-99443 (not 99331). That description specifies 5-10 minutes, so no time documentation means non billable service.
 
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