decisionhealth Newsletters, Coder Pink Sheets - 2009 Issue 8 (August)
Tips to time your services just right when reporting time-based codes
Subscribe or sign in to view the full article.
Article Overview
This article reviews documentation expectations for time-based coding in physician office, outpatient, inpatient, observation, discharge, prolonged services, and critical care settings. It focuses on the general types of time documentation payers expect, common documentation pitfalls, and the kinds of supporting information carriers may request. The discussion is relevant for OB/GYN practices, coders, billers, and compliance staff working with Medicare and CPT-based evaluation and management reporting.
Why This Topic Matters
Accurate time documentation can affect whether time-based services are paid, downcoded, or denied. The article helps readers understand the broad documentation themes and payer concerns that influence compliant reporting.
Article Sections
-
Documentation expectations for time-based services
Introduces the need for adequate time documentation and summarizes payer concerns about missing or incomplete time references.
-
How time may be documented
Discusses broad approaches to recording service time and the general types of phrasing payers may view as too vague.
-
What time generally should not be counted
Reviews the difference between billable service time and time that is typically excluded depending on the site of service.
-
Counseling and coordination of care in E/M reporting
Summarizes general guidance on E/M visits where counseling or coordination of care influences code selection and documentation.
-
Additional time-based coding points
Covers broader payer and documentation issues involving time-based services, including who may contribute time and how prolonged or critical care time is generally framed.
-
Official resources
Lists referenced carrier and CMS resources for further reading.
What You Will Learn
- How time-based service documentation is generally expected to appear in the record
- What broad categories of time may be excluded from total time depending on setting
- What additional documentation elements may be requested for counseling or coordination of care
- How payer review can affect time-based E/M service reporting
- What general time-based coding issues arise in prolonged services and critical care reporting
Who Should Read This
- ObGyn physicians
- Medical coders
- Medical billers
- Compliance staff
- Practice managers
- Audit and compliance reviewers
Codes Discussed
Code Ranges Discussed
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com