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tci E/M Coding Alert - 2020 Issue Q4

You Be the Coder: Be Patient When Billing Inpatient Visits by Time

Question: Our gastroenterologist saw a colitis patient in the hospital and did not maintain thorough notes about the history or exam. However, he documented that he spent 36 minutes on the encounter and discussed treatment options with the family. The visit does not constitute critical care, so how can we bill this service? Georgia Subscriber Answer: You may be able to bill this encounter based on time, since the physician noted the time spent and what was discussed. However, you must ensure that the documentation is clear about how much of the visit was spent in counseling/care coordination &mdash...

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