tci Medicare Compliance & Reimbursement - 2008 Issue 14

Reader Question: Document Time Spent On Counseling

Make sure to note the ratio of total visit time to counseling time Question: One of our insurers downcodes my evaluation and management (E/M) visits because the diagnoses don't support the service levels that I billed. But I coded these visits based on time, not E/M elements. How can I get paid for higher-level counseling visits? Answer: To prove that a visit qualifies for time-based E/M billing, make sure the documentation includes the ratio of the total visit time to the counseling time. This will show the payer that you spent most of the visit (more than 50 percent)...

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