Results 1 to 5 of 5

Time Based Visit

  1. #1
    Question Time Based Visit
    Medical Coding Books
    Hi, I am new to E/M coding and trying to understand how to document a time based visit (counseling &/or coordination of care >50%) for Psychiatry.

    My understanding, is they only have to document:
    1. Total time of visit
    2. State that visit consisted of >50% counseling and/or coordination of care.
    3. Briefly describe counseling &/or coordination of care topics.

    They don't have to include Hx, Exam, & MDM documentation. So, it may be a short note. Is this correct? It just seems to simple to me. Thanks for your input!

  2. #2
    North Carolina
    You've got it~

    When you devote more than 50 percent of your face-to-face time with the patient to counseling or coordinating care, time may be considered the key or controlling factor to qualify for a particular level of E/M service.

    An example of documentation would be:

    "30 minutes of face to face was provided;more than 50% of which was devoted to counceling" (also include what was discussed)

    I also encourage my providers to document the "beginning and ending" time. Some do this better than others.

    Last edited by RebeccaWoodward*; 02-29-2008 at 06:56 PM.

  3. #3
    Great! Thanks so much for the response!

  4. #4
    Red face Teaching Physician
    I am not clear on what a teaching physician (TP) has to document for a time based code in addition to the residents note. This is my understanding:

    1. TP performed the service or was physically present during the key or critical portions of the service when performed by the resident.

    2. Participation of the TP in the management of the patient.

    (Would the above 2 items be the "describe counseling and/or coordination of care" criteria?)

    3. Time TP was present (I am not sure if this is required in the note. I know they can only bill for the time they are actually present and not combine their time with the residents. I am thinking the only way to know this is to ask them to document their time?).


  5. #5
    North Carolina
    Take a look at 100.1.4

    Does this help?
    Last edited by RebeccaWoodward*; 03-04-2008 at 03:32 PM.
    Rebecca CPC, CPMA, CEMC

    Your click COUNTS...

    CLICK to give FREE mammograms!

Similar Threads

  1. Office visit based on time
    By eharn in forum E/M
    Replies: 4
    Last Post: 09-11-2014, 10:56 PM
  2. Level 5 EP visit based on time
    By ollielooya in forum E/M
    Replies: 2
    Last Post: 01-18-2013, 05:20 PM
  3. 21 minute est pt EM visit based in time
    By 1073358 in forum E/M
    Replies: 2
    Last Post: 11-23-2011, 10:51 AM
  4. Visit based on time
    By lgrennan in forum Pediatrics
    Replies: 4
    Last Post: 05-23-2010, 10:22 PM
  5. Initial visit based on time only ???
    By Orthocoderpgu in forum E/M
    Replies: 3
    Last Post: 10-19-2009, 07:03 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.