tci Medicare Compliance & Reimbursement - 2008 Issue 14
Reader Question: Document Time Spent On Counseling
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Article Overview
This premium article addresses a coding documentation question about evaluation and management visits billed based on time rather than E/M key elements. It is aimed at medical coders, billers, and clinicians who document counseling and coordination-of-care services, and it discusses how visit notes should reflect total time, counseling time, and related payer review concerns under CPT E/M guidance.
Why This Topic Matters
Accurate time documentation can affect whether a payer accepts a higher-level E/M service when the medical record is reviewed. The article helps readers understand the type of documentation expected when counseling time is the basis for billing and when an appeal may be needed.
What You Will Learn
- How time-based E/M billing is supported in documentation
- What information should appear in a note when counseling is the basis for a visit level
- Why payer review may differ from the coder’s selected service level
- How appeals may relate to documentation of counseling and coordination of care
Who Should Read This
- Medical coders
- Billing specialists
- Physicians and other qualified health care professionals
- Practice compliance staff
Codes Discussed
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