AAPC - Back to school
Results 1 to 4 of 4

Thread: billing based on time

  1. #1

    Default billing based on time

    AAPC: Back to School
    When billing based on time, is it still necessary to document the HPI, exam and MDM? If you document the time, with a brief description of what was discussed with the patient in the counseling, does this meet the
    guidelines for billing that level?

    We have a physician who takes a VERY long time to complete his notes. Since we do not bill for a visit until the note has been completed we are running into a timely filing issue. If we could simplify things for him, we might be able to get his billing submitted on time. One possible solution was to have him document a chief complaint and a brief description of what was done. For example "I spent 40 mintues with the patient, and more than 50% of the visit was spent in counseling the patient about the progression of her disease and possible treatment options." In your opinion, would this be enough documentation to bill a 99215? (if there is no documentation of an HPI, exam or MDM)
    Last edited by Colliemom; 08-07-2008 at 02:17 PM.

  2. #2
    Join Date
    Apr 2007


    Are you asking if it is okay not to do it or not to document it? I feel anything that is done should be documented, regardless of the impact it has on coding. The time it takes provider to obtain history, perform exam and counsel pt. is all part of the face-to-face time and you will want to add this in as well.

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default I responded in Gastroenterology track

    F Tessa Bartels, CPC, CPC-E/M

  4. #4


    you don't have to document the hx, ex, mdm if you're billing based on time from a coding/billing perspective. you can simply state the time spent face to face (office/outpatient) or floor/unit time (inpatient) and that more than half of the encounter was spent counseling/coordinating care. to back up the time, you really only have to have a short sentence like above plus what was discussed (not necessarily involving the 3 key components)

    however, always remember there is a clinical aspect they must meet. to protect themselves and inform other professionals they should always include more than just "30 minutes spent face to face counseling/coordinating care for patient's diabetes"
    therefore, i always say document whatever you do...if time is a factor and allows higher coding, then great.

Similar Threads

  1. Billing based on time
    By MidwestCoder in forum E/M
    Replies: 8
    Last Post: 07-16-2013, 09:21 AM
  2. Time Based E/M Billing
    By jcochran in forum Behavioral Health
    Replies: 1
    Last Post: 07-15-2011, 07:23 PM
  3. Time based E/M Billing
    By jcochran in forum E/M
    Replies: 1
    Last Post: 06-17-2011, 08:05 AM
  4. Billing Based on Time
    By renifejn in forum E/M
    Replies: 7
    Last Post: 04-09-2009, 07:40 PM
  5. Billing Based on Time
    By maryan611 in forum E/M
    Replies: 3
    Last Post: 10-03-2008, 05:17 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.