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Time based E/M

  1. #1
    Location
    Durham, NC
    Posts
    39
    Default Time based E/M
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    We have some doctors that do not put in their documentation the time spent, but based on averages we know that they spent more than 50% counseling.

    Example:
    discussion with pt and family on hospice placement
    discussion with staff concerning pt's status
    discussion with oncologist

    If there is nothing from the doctor on time spent, can the time based coding be used be inserted by the coder?

  2. #2
    Location
    Columbia, MO
    Posts
    12,561
    Default
    If total face to face time is not documented then there is no way for you to use time based coding. It cannot be used based on a supposition. If this is an inpatient then you must have the total bed time with the patient plus the floor time must also be documented and then added to the bed time. unless you have met the parameter of 30 minutes beyond the visit level time then there is no prolonged time that can be added.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default Inpatient
    Be careful with INPATIENT coding ... some payers will only allow you to count face-to-face time.

    I absolutely agree with Debra ... NO, the coder can not add time. The physician is responsible to accurately document his/her services. The coder is responsible for translating that documentation into the correct code.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Location
    Durham, NC
    Posts
    39
    Default
    Thank you. I thought as much. Does anyone know of documentation? I have a coder that needs to see the rule.

  5. #5
    Location
    Minneapolis MN
    Posts
    84
    Default
    The 1995 Documentation Guidelines give direction on how to bill based on time - page 15.

    http://www.cms.gov/MLNProducts/Downloads/1995dg.pdf

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