CODING & DOCUMENTATION

 


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Fam Pract Manag. 2015 Sep-Oct;22(5):48.

Author disclosure: no relevant financial affiliations disclosed.

Documenting time for preventive services

Q

We are being told that we must document time separately for Medicare preventive services that include time in the code descriptor when these services are provided in conjunction with an annual wellness visit or evaluation and management service. Is this correct?

Yes. There is nothing in the Medicare guidance that exempts these services from the requirement to document start and stop times or total time spent providing the individual service. It is important to note that although several services include “15 minutes” in their descriptor to indicate a minimum time threshold for reporting, the National Coverage Determinations Manual indicates that the Centers for Medicare & Medicaid Services will cover annual screening for depression up to 15 minutes for Medicare beneficiaries when staff-assisted depression care supports are in place to ensure accurate diagnosis, effective treatment, and follow-up. In other words, time must be documented, but 1 minute to 15 minutes are covered in this case. Be sure to also use the “5 As” approach (assess, advise, agree, assist, and arrange) to document services that require counseling. An example would be behavioral counseling for alcohol misuse, which would need to include evidence that the counseling was consistent with the 5 As approach.

Drug screening in the office

Q

What are the appropriate codes to report for drug screening performed in our office to rule out illicit drug use, confirm appropriate use of prescribed pain medications, or comply with state guidelines for prescription of controlled pain medications?

Code 80300 is typically appropriate for reporting in-office screening for presence of drugs (qualitative screening), such as screening for compliant use of prescription drugs. However, there are exceptions for patients with Medicare and payers that follow Medicare policy

About the Author

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Cindy Hughes is an independent consulting editor....

These answers were reviewed by members of the FPM Coding & Documentation Review Panel, including Kenneth Beckman, MD, MBA, CPE, CPC; Robert H. Bösl, MD, FAAFP; Marie Felger, CPC, CCS-P; Thomas A. Felger, MD, DABFP, CMCM; Emily Hill, PA-C; Joy Newby, LPN, CPC; and Susan Welsh, CPC, MHA.

Author disclosure: no relevant financial affiliations disclosed.

WE WANT TO HEAR FROM YOU

Send questions and comments to fpmedit@aafp.org, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.


 

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