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Time based E/M

  1. #1
    Durham, NC
    Default Time based E/M
    Medical Coding Books
    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.

    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
    Columbia, MO
    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
    Milwaukee WI
    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
    Durham, NC
    Thank you. I thought as much. Does anyone know of documentation? I have a coder that needs to see the rule.

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

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