Tighten Up Your Documentation for Coding E/M Based on Time
By Christine Taxin
January 09, 2017
One of the biggest questions Laurie and I receive is how to pick the code for the office visit. If you have or are thinking of attending one of our hands-on meetings you will receive a lot of training on the codes that describe types of visits. Below is a short description of what takes place at our courses. Come join the Viva Las Vegas Group of proficient billers who have gone thru our training. Contact us at 914-303-6464 to go over dates and places we are speaking.
PS a big surprise opening of our online school will be announced very soon. Stay tuned.
If you almost always choose your E/M codes based on history, exam, and medical decision-making (HEM), you may be hesitant to code based on time. But ignoring this opportunity could be leading you to report lower level E/M codes that reimburse at a lower rate than you deserve. Take your time-based coding confidence up a notch with these documentation tips.
Tip 1: Know What the Authoritative Rule Says
The first step to knowing what documentation is required is simple: read the official rule. Attending a Links2Success Program is a great first step.
The rule states that when a provider spends more than 50 percent of an encounter on counseling and/or coordination of care, then you can use time as the controlling factor to determine the E/M level.
In the office setting, this refers to face-to-face time. Floor/unit time counts in a hospital or nursing facility.
The rule also states, “The extent of counseling and/or coordination of care must be documented in the medical record.”
Tip 2: Look for Total Time and Time on Counseling
To feel secure that coding an E/M based on time will stand up to scrutiny, work with providers to document both total time for the encounter and the amount (or percentage) of time spent on counseling and/or coordination of care. Using start and stop times for both the visit total and the counseling portion is another good method, and some EHRs may have features to help with this.
Do this: Documentation that “I saw this patient face-to-face for 27 minutes and spent 15 minutes of the encounter on counseling the patient” shows the provider spent more than 50 percent of the 25-minute visit on counseling.
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