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Addendum to notes

David Posted Tue 24th of February, 2015 13:11:28 PM

At our practice, we have 2 new coders, both with no previous experience, so I don't know how this was handled in the past as when we came in...there were no coders that had been here to train us.

We have found that many times the office visits have the time documented, but not in the appropriate way where we can code based off time. So we are billing much lower E/M's. We have brought this to the Office manangers/supervisors attention. They are telling us that we can request to have the wording changed by transcription in these cases by them adding ">50% spent counseling/coordinating care". (which is all that is missing). So transcription will doing an addendum.

When the time is misdocumented, I do not feel I can ask for the wording to be changed just to get to a higher level. I am wrong?

Thank you

SuperCoder Answered Wed 25th of February, 2015 06:48:24 AM

Hi, thank you for the query.
There are two ways of coding office visits. One is time bases and another is HEM based i.e. History, Examination and Medical Decision Making (MDM) based.
While coding based on time, whatever amount of time has been mentioned, that should be spent face to face with patient and/or family, which is enough to code that level. For example- If physician spent 25 minutes face to face with the patient and/or family, so 99203 will be billed. So, it could be mentioned in the record that the time spent with the patient and/or family is face to face along with whatever time is given.
Else it can be coded on the basis of HEM.
Thank you

David Posted Wed 25th of February, 2015 10:48:20 AM

If we are audited it also has to say " >50% of it was spent counseling/coordinating care"....that is what CPT states as well as CMS. That is the question.....a lot of the providers are already mentioning how much time is being spent.....but they fail to add that phrase above, so we are not coding based off time. Can the transcriptionist change that in the notes, or should it be done by the provider? Of course it would only be changed if it is true....but in all cases we are coming across it is...they just are leaving out that phrase.

SuperCoder Answered Thu 26th of February, 2015 03:41:08 AM

Hi Burow, thank you for the query.
Use time as the controlling factor to report an office and/or other outpatient visit if more than 50% of the visit is comprised of counseling and coordination of care.
It has to be done by the provider.
If he actually spent time for counseling/coordinating care, then only he can change and add it as an addendum.
Otherwise you can educate the provider with proper guidelines to avoid future mistakes.

Hope it help you.

Thank you

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