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Time Based E/M Billing

  1. #1
    Default Time Based E/M Billing
    Medical Coding Books
    We would like to start using the time based E/M billing, I have a quick question. Both the 1995 and 1997 CMS guidelines state that:

    In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.
    !DG: If the physician elects to report the level of service based on counseling
    and/or coordination of care, the total length of time of the encounter (face-to-face or
    floor time, as appropriate) should be documented and the record should describe
    the counseling and/or activities to coordinate care.

    I am unsure whether or not we would still need to meet the 3/3 or 2/3 guidelines as far as history, exam, MDM, etc... I have been unable to find a definitive answer anywhere.

    As long as we document total face to face time with client in counseling and/or coordination of care, as well as medications/care discussed, what else do we need to document on each visit?

  2. #2
    Default Reference
    Last edited by jackson7591; 07-17-2011 at 08:56 PM.

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