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Emr

  1. #1
    Default Emr
    Medical Coding Books
    Hi all-need some input-I am doing some coding for a client and some of the records are from an emr. Here is the problem-I went through a visit and coded as a 99213 (that was the level supported) however at the end of the dictation it says "60 minutes spent face to face with the patient->50% of the visit." Pt presented with bilat earaches! I am really, really, really struggling-I just can't bring myself to code a level 5! Thoughts? Thanks!

  2. #2
    Location
    North Carolina
    Posts
    3,126
    Default
    Wow...that's interesting. Medical necessity might be an issue for this one. Are you able to post the note so we can get a better feel for what went on during the visit? Makes me wonder if this is "templated" in the EMR...

  3. #3
    Default
    It is a templated emr.....and the medical necessity is not there. I am not able to post-sorry.

  4. Default
    Coding on time requires documentation of:
    1) total encounter time
    2) time spent counseling/coordinating
    3) "sufficient detail" to support time claimed as C&C

    Unless there was documentation in the note of how he spent at least 31 minutes C&C, then I would not code based on time

    Second....I wouldn't take the 50% click as anything. Previous worksite the physicians had no clue on the 2 "clicks" in EMR for the encounter time and the 50%. They always clicked the 50% box because that is how the IT systems people (not understanding the coding implications) trained them. In addition, the encounter time always defaulted to the appt time. If the appt was booked or 20 min the box (and the note) showed 20 min even thou the physican often spent less and sometimes more.

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