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How to document/specifiy "time "in audit, HELP

  1. Default How to document/specifiy "time "in audit, HELP
    Medical Coding Books
    Hi there, i need to know exactly how specific my Dr. needs to be in documenting his time for a 99214 to be bumbed up to a 99215 based on time.
    He states,
    "40 minute visit with 50% spent on counseling patients medical conditions".

    I was told this is not sufficient. He needs to document the exact time in minutes spent counseling, and then what exactly he counseled as well.

    Does any one else have any input?

  2. #2
    Default time
    Have you looked at using the prolonged visit codes in addition to the E/M, rather than trying to fit the documentation to a 99215?
    In CPT book professional edition 2009 page 25-26 gives information on prolonged visits.

  3. #3
    You are correct. AMA/CMS guidelines if coding based on time:
    "If more than 50% of the time spent FACE TO FACE with the patient is for counseling or coordination of care, you can use time as the determining factor for coding services. To document time as the key factor in code selection":
    1: Indicate the TOTAL FACE TO FACE time spent with the patient
    3: Provide a DETAILED description of what was discussed.

    link to CMS 1995 and 1997 Documentation Guidelines:

    If the doc does not fully document time spent in counseling or coordination of care AND what was discussed you can nuse time as a determining factor.

  4. #4
    Milwaukee WI
    Default More than 50%
    Note carefully the requirement that MORE THAN 50% of the total time spent must be in counseling/coordination of care in order to use time as the determining factor for the level of service.

    Some carrier DO allow the language "greater than 50% of this time ..." Other carriers want the time specified: I spent a total of 40 minutes, 25 minutes of which was in counseling regarding xxxx."

    F Tessa Bartels, CPC, CEMC

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