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Physician billing almost exclusively based on time

  1. #1
    Default Physician billing almost exclusively based on time
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    I browsed through the many posts on this topic, but I didn't see any responses to this particular problem.

    I have a physician who bills 90% of his office visits based on time. I tried to make the argument that not all visits should be billed based on time for counseling the patient, but my physician argues that since he is a specialist, counseling the patients is appropriate.

    I am about to have another discussion/debate of this issue with the physician. Can anyone help me with key points that need to be addressed? Also, can anyone direct me to any online articles or websites that would provide support for my argument that not all office visits should be billed based on time?

    Finally, if you don't think billing 90% of a physician's office visits based on time is a problem, please let me know why.


  2. #2
    I had a provider that billed 100% of her visits based on time. I ran it by WPSMedicare and they said as long as it was medically necessary and documented correctly it was fine. When I pushed on the medical necessity piece they would not give me more info. That is the only thing I struggle with. I have yet to find anywhere that defines what supports medical necessity of time based coding.

    My provider was a specialist, perinatology. So there really wasn't any exam she could do, her paitient was the unborn baby, not the mom. Time is the only option for new/consult visits that are 3 of 3 for key components.

    Laura, CPC, CPMA, CEMC

  3. #3
    North Carolina
    I also have a specialist that codes most of his visits based on counseling. He is an infertility specialist and his documentation does support medical necessity and the code submitted.
    Rebecca CPC, CPMA, CEMC

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  4. #4
    I can see the medical necessity for these two physicians, but my physician is a gastroenterologist. He bills for counseling the patients for a variety of issues, and I am not sure these meet medical necessity as the other physicians in the practice only occassionaly bill based on time.

    examples of his billing based on time for counseling would be:
    history of peptic ulcer disease
    weight loss
    pt with epigastric pain, nausea, bloating and anorexia

    Almost all his established patient visits are billed as 99214, because he usually spends 25 minutes with each patient counseling them on their disease and treatment options. It just seems to me that with established patients, the plan of care has already been why would it be medically necessary to counsel them for more than 50% of each visit? He is the physician and therefore he needs to determine if the patient needs to be counseled, and I feel a little hesitant to question him on the medical necessity of all these counseling visits. But this just doesn't seem to meet medical necessity in my opinion. And also the fact that all these visits are 25 minutes long, not 30 or 35 or even 20, make me worry he could be throwing up a red flag for an audit. What do you think?

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