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Need opinions on time documentation

  1. #1
    Question Need opinions on time documentation
    Exam Training Packages
    This is an established patient that they have made a decision to do surgery in this visit just pending the patients final decision.

    Detailed history, problem focused exam, MDM of moderate. At the end of the note I have this

    "Overall I spent about 40 minutes with Ms. Patient and her family this morning and the vast majority of this time was spent with medical decison making."

    Another coder selected 99215. I'm not really comfortable with this due to the reference to MDM.

    Insight is greatly appreciated.

    Thanks

    Laura, CPC, CPMA, CEMC

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default Counseling Coordination of Care
    When you use time spent in counseling/coordination of care you do not need to meet ANY of the elements to determine the level of code.

    40 minutes with an established patient and his/her family counts as a 99215.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Default
    But he says the majority of the time was spent doing one of the elements that you don't count when coding based on time. This is my hang up on this one.

    Laura, CPC, CPMA, CEMC

  4. #4
    Default Coding Based on time
    CODING BASED ON TIME:
    You must document the total face-to-face time with the patient, and either the amount of time counseling/coordinating care, or that over 50% of the time was spent counseling/coordinating care.
    Example: “I spent 30 minutes face to face with the patient and 20 minutes counseling/coordinating care”. Or “I spent 30 minutes face to face with the patient and over 50% of the time was spent counseling/coordinating care”. The note would also need to have in it what was actually discussed/counseled on.

  5. #5
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    I see what you are having issue with Laura. Stating that the 40 minutes was spent discussing MDM would not count in my book. The note must state a summarization of counseling, so "MDM" does not seem appropriate to me. Also, "vast majority" is not really stating greater than 50%...I think I would not count the time and go with the key components.
    Lisa Bledsoe, CPC, CPMA

  6. #6
    Location
    Milwaukee WI
    Posts
    4,466
    Default The way I interpreted the documentation
    The way I interpreted the physician documentation statement was that s/he spent more than half the time discussing treatment options, risks/benefits. Had the physician stated just that, there would be no question that this was counseling/coordination of care.

    I agree that the actual way this was stated is not clear, however.

    F Tessa Bartels, CPC, CEMC

  7. #7
    Location
    Ellenville, New York
    Posts
    1,176
    Default Lacking time specifics
    With the lack of detail for amount of time spent counseling (I too don't like "vast majority"), I would use 99214 for the detailed hx and moderate MDM.

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