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Time based coding - need refresher please

  1. Default Time based coding - need refresher please
    Medical Coding Books
    Hello,

    I have physicians that will document an E/M level say for an office follow up, after auditing it will come out to a 99215 based on E/M elements. Ok of the same note they will document something like this.. " I have spent 30 minutes total time with the patient discussing treatment options and a plan of treatment.

    Ok, a 99215 equals to 40 minutes.. which takes precedence? The E/M level of the note 99215 or the fact that they documented the total time with the patient of 30 minutes? I have been told by the physician (s) that they have indeed spent 30 minutes. So in this scenario are they short changing themselves? I say they are.. I am sorry I was not more specific in my previous entry.

    Anyone else?

    Thanks!
    Last edited by Love Coding!; 01-12-2012 at 11:06 AM. Reason: Added more detail to my post

  2. #2
    Location
    Ellenville, New York
    Posts
    1,177
    Default Use the elements
    If documenation of the elements supports 99215, use that. The 40 minutes for time spent is what amount of time is "typically" spent with the patient.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  3. Default
    Quote Originally Posted by MnTwins29 View Post
    If documenation of the elements supports 99215, use that. The 40 minutes for time spent is what amount of time is "typically" spent with the patient.
    Thank you Lance, don't you think they would be short changing themselves if their note reflected a higher level of service than what they documented for "total time". I want to break them out of the habit of doing this. I feel this would be a great educational opportunity on time based coding.

    Thanks,

  4. #4
    Location
    Concord, NC or Rochester, NY
    Posts
    154
    Default
    Time based can only be used when a visit turns to consulting. If they are documenting the key elements and not performing counselling, then the key element is the only way to go. The average time in CPT is only that - the average time. It is this time that is utilized when looking at time based coding but don't let anyone tell you to use the time when there is no type of counselling, etc.

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default Experienced clinician
    An experienced clinician can perform and document a 99215 in FAR less time than 40 minutes.

    Don't worry about it. You may code to whichever standard is met ... You say that key elements = 99215, so you are fine coding 99215.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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