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Coding based on "time spent"

  1. Default Coding based on "time spent"
    Medical Coding Books
    Just a quick question regarding billing on time spent: If the provider documents time spent & that more than 50% was spent in counseling/coordination of care, and so we bill the level based on time...are we then forced to bill ALL patients notes on time spent?
    Or the next patient the provider sees, could we then code based on bullets/MDM, etc?

    The question has been brought up because someone thought we couldn't "flip flop" back & forth, must code all patients the same way. If you're going to code one based on time spent, you must code all notes based on time spent is their thought.

    Any advice is appreciated, thanks in advance!

  2. #2
    Hartford, CT
    You code based on the documentation. Each note is coded based on its' own merits. Coding office visits based on time should not be the norm.
    Doreen Clark, CPC, CPMA
    Medical Auditing Specialist
    Integrated Physicians Management Services
    East Harftord. Ct

  3. Default
    if time spent is not documented on future medical records, it is not considered.

  4. Default
    If a physician has the documentation needed to bill a high level E&M for an established patient visit but documents time spent was 20 minutes in coordinating patient care etc (all the necessary statements necessary to use a time based code > 50% of the tiem spent on counseling regarding patient, etc. Can the encounter be billed on the documentation to use the higher level or does the encounter need to be billed based on the time because it is stating >50% time spent on counseling?

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