CODING & DOCUMENTATION
Fam Pract Manag. 2016 Jan-Feb;23(1):34.
Author disclosure: no relevant financial affiliations disclosed.
- Coding based on time
- Diagnosis coding and EHR documentation
- ICD-10 “additional codes”
- Otitis media follow-up visit
Coding based on time
I understand that physicians can bill E/M visits based on time or the levels of history, exam, and medical decision-making. If a physician billed the E/M service based solely on time but documented the history, exam, and medical decision-making, would that be acceptable?
That would not be acceptable unless the documentation also indicated that the requirements for time-based billing were met. If more than 50 percent of the face-to-face time of the encounter was spent counseling or coordinating care, coding based solely on time is permissible. The key components of history, exam, and medical decision-making may be used to determine the level of any E/M visit and must be used if the visit doesn't meet the criteria for time-based coding.
The 1995 and 1997 E/M guidelines include differing instructions for coding based on history, exam, and medical decision-making, but the instructions for coding based on time are the same: Document the total length of the encounter (face-to-face or floor time, as appropriate), note that more than 50 percent of that time was spent providing counseling or coordinating care, and provide examples (e.g., “answered patient questions regarding withdrawal and weight gain and gave recommendations for diet and exercise in addition to smoking cessation plan”). Some payers may require documentation of both total visit time and an estimate of the time spent in counseling (e.g., 20 of 30 minutes).
Diagnosis coding and EHR documentation
Our electronic health record allows physicians to select a diagnosis code and then incorporates the code and descriptor into the progress note. Does the physician also need to list each diagnosis in the assessment portion of the note?
Yes. Physicians must document a diagnostic statement and assign codes. Many diagnosis codes represent more than one condition, and code descriptors may
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Send questions and comments to firstname.lastname@example.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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