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Documentation requirement for time-based code

  1. #1
    Ellenville, New York
    Default Documentation requirement for time-based code
    Medical Coding Books
    Is this line sufficient? "Total face to face time 45 minutes, with > 50% spent counseling." Or does the time spent counseling need to be specified, i.e. "Total face to face time 45 minutes, 30 minutes of which was spent counseling." The former meets CPT requirements and seems okay, but am curious as to what others require.


  2. #2
    Everett, WA
    From expert advice I've received from one of the forum members you would be wise to include the "nature of the counseling", too. So, the simpliest way to accomplish this would be the statement "I spent an additional _____ minutes in direct patient care due to ________. This advice has been so helpful to me as well as to others.---Suzanne Byrum CPC

  3. #3
    Evansville Indiana
    Default Time
    Per NGS, also needs to meet medical necessity.

  4. #4
    True, there needs to be at least a couple of sentences detailing what was the reason for counseling/coordination of care.
    Q1. When using time as the determining factor for inpatient evaluation and management (E/M) services, does greater than 50% of the time have to be spent in counseling/coordinating care (C/C), or is documenting total time spent on the unit/floor sufficient documentation?
    A1. A provider may only use time in choosing the procedure code when spending more than 50% of the total face-to-face time of the visit in counseling / coordination of care. Documentation of the total time of the visit, the time spent in counseling/coordination of care and the nature of the counseling/coordination of care must be in the medical record.

    If the medical record does not reflect the required documentation, then use the three key elements of history, exam, and medical decision-making to choose the procedure code.

    In the office setting, document the total face-to-face time with the patient. In the inpatient setting, document the total face-to-face time with the patient or on the patient's floor or unit. The face-to-face time refers to time spent with the physician only. Time spent with other staff is not considered in selecting the appropriate level of service.

  5. #5
    Milwaukee WI
    Default Audit proof vs okay
    It is okay to document the TIME as you stated. HOWEVER if you really want it to be audit proof documentation will note the total time spent face-to-face, AND the time spent in face-to-face counseling (which has to be 51% or more of total time). ADDITIONALLY, the nature of the counseling needs to be stated.

    This does not have to be exhaustive.

    For example: "Total face to face time 45 minutes, with > 50% spent counseling regarding diagnosis, risk and benefits of various treatment plans and expected outcomes."

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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