rtkalvin
Guest
Is it necessary to document time in the base service(E/M) note in addition to documenting time in the prolonged service note?
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Wiki Time documented in Prolonged Service note.
- Thread starter rtkalvin
- Start date
hewitt
Expert
Here is a link for Medicare's documentation requirements for NYC: http://www.cms.gov/transmittals/downloads/R1875CP.pdf Take a look at pages 23-24. Hope this helps!
FTessaBartels
Guest
It depends
If you are coding the primary E/M based on key elements, no, you don't need to document the time spent.
If you are coding the primary E/M based on counseling/coordination of care (i.e. time), then, YES, you have to have to entire time spent face-to-face with the patient, including the basic E/M code as well as the prolonged service (if applicable).
Hope that helps.
F Tessa Bartels, CPC, CEMC
If you are coding the primary E/M based on key elements, no, you don't need to document the time spent.
If you are coding the primary E/M based on counseling/coordination of care (i.e. time), then, YES, you have to have to entire time spent face-to-face with the patient, including the basic E/M code as well as the prolonged service (if applicable).
Hope that helps.
F Tessa Bartels, CPC, CEMC
mdoyle53
Guest
Absolutely
Since the Prolonged service is based on time above and beyond the average CPT E&M time, it is necessary to document time, otherwise the record would not have enough
documentation to denote a prolonged Service
Since the Prolonged service is based on time above and beyond the average CPT E&M time, it is necessary to document time, otherwise the record would not have enough
documentation to denote a prolonged Service
rtkalvin
Guest
Thanks everyone