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Time documented in Prolonged Service note.

  1. Default Time documented in Prolonged Service note.
    Medical Coding Books
    Is it necessary to document time in the base service(E/M) note in addition to documenting time in the prolonged service note?

  2. #2
    Location
    Manhattan, NY
    Posts
    390
    Default
    Here is a link for Medicare's documentation requirements for NYC: http://www.cms.gov/transmittals/downloads/R1875CP.pdf Take a look at pages 23-24. Hope this helps!

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default It depends
    If you are coding the primary E/M based on key elements, no, you don't need to document the time spent.

    If you are coding the primary E/M based on counseling/coordination of care (i.e. time), then, YES, you have to have to entire time spent face-to-face with the patient, including the basic E/M code as well as the prolonged service (if applicable).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Location
    Concord, NC or Rochester, NY
    Posts
    154
    Default Absolutely
    Since the Prolonged service is based on time above and beyond the average CPT E&M time, it is necessary to document time, otherwise the record would not have enough
    documentation to denote a prolonged Service

  5. Default
    Thanks everyone

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