Bonnie Posted Wed 13th of June, 2012 00:55:40 AM
If physician states that "More than 40 minutes was spent counseling the patient and her husband" and no physical was done, is it OK to bill this with EM based on time of 40 minutes even though it does not state ie 40 minutes with over 50% of time spent counseling. Does the 50% language always need to be included in the time statement.
SuperCoder Answered Wed 13th of June, 2012 16:55:23 PM
Yes this is a must.Keep in mind: the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services’ (CMS) guidelines consider history, exam, and MDM to be the key components of E/M services, and allow coding by time only when 50 percent or more of the visit involves documented counseling and/or coordination of care. The physician should include the components of history, exam, and MDM—even if cursory—in the documentation of every visit. Good medical record keeping requires documenting relevant and pertinent information. Using time as the controlling factor to qualify for a given E/M level does not negate this requirement.