tci E/M Coding Alert - 2013 Issue 1

Time-Based Coding: Ensure Your Provider is Documenting 3 Key Points for Billing on Time Alone

Remember that counseling and coordination of care must dominate the encounter. If you’re coding office visits based on the time your physician spends with a patient providing counseling or coordination of care, make sure he is documenting three critical pieces of information — and we don’t mean history, exam, and medical decision making.  Otherwise, you’ll face payer take-backs, or worse.  Even if your physician says that he spent over an hour with a patient, you can’t automatically report 99215 (Office or other outpatient visit for the evaluation and management of an established patient...

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