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Patient remained at office for 6 hours

  1. #1
    Pittsburgh Central Pennsylvania
    Default Patient remained at office for 6 hours
    Medical Coding Books
    Our physician performed an office visit on a patient and gave the patient an oral medication due to the patient's diagnosis. Because the medication given is new to the market, our physician had the patient stay in the office for six hours and periodically checked on him/her to make sure there were no adverse side effects from the medication.

    Physician is interested in billing for the additional time/supervision given to the patient.

    Anyone have any suggestions? E/M is not my strong-suit.. any suggestions are greatly appreciated! Thank you.

  2. #2
    Columbia, MO
    The only billable time is the face to face physician to patient time and must be documented in the medical record by the physician for each time he was in the room. Such as time in x:xx and time out X:XX or time spent 5 min, then another 5 min etc. then IF there is enough time ie 30 minutes beyond the visit level time, for instance if a level 3 were documented then a TOTAL of 45 minutes spent face to face would give you a 99213 plus a 99354. But time spent all along the way must be documented, that means time spent for the ov plus the additional time each time the patient was checked on.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Pittsburgh Central Pennsylvania
    Thank you so much for your help!

    Beth B

  4. #4
    Is this for Gilenya?
    Mandy Flagg, CPC, CEMC
    Compliance Auditor

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