![]() The total length of time of the E/M visit.2 The following must be documented in the patient’s medical record in order to report an E/M service based on time: When counseling and/or coordination of care dominate more than 50% of the time a physician spends with a patient during an evaluation and management (E/M) service, then time may be considered as the controlling factor to qualify the E/M service for a particular level of care. Initial and Subsequent Acute Care Service Issues Addressed Once the provider documents all services rendered on a given calendar date, the provider selects the visit level that corresponds with the cumulative visit time documented in the chart (see Tables 1 and 2). Time associated with teaching students/interns is also excluded, because this doesn’t reflect patient care activities. reviewing current results or images from the physician’s office) is not allowable in calculating the total visit time. Time associated with activities performed in locations other than the patient’s unit/floor (e.g. For inpatient services, total visit time is identified as provider face-to-face time (i.e., at the bedside) combined with time spent on the patient’s unit/floor performing services that are directly related to that patient, such as reviewing data, obtaining relevant patient information, and discussing the case with other involved healthcare providers. ![]() Time is not used for visit level selection if C/CC is minimal (<50%) or absent from the patient encounter. To make sure that this qualifies as a time-based service, ensure that the documentation contains the duration, the issues addressed, and the signature of the service provider.ĭuration of Counseling and/or Coordination of Care Coordination of care for outpatient programs and resources is also crucial. In addition to stabilizing the patient’s glucose levels and devising the appropriate care plan, the patient and/or caregivers also require extensive counseling regarding disease management, lifestyle modification, and medication regime. They should update the medical decision-making based on the discussion.Ĭonsider the hospitalization of an elderly patient who is newly diagnosed with diabetes. 1 In these instances, providers may choose to document only a brief history and exam, or none at all. Sometimes providers may report a lower service level than warranted because they didn’t feel that they spent the required amount of time with the patient however, the duration of the visit is an ancillary factor and does not control the level of service to be billed unless more than 50% of the face-to-face time (for non-inpatient services) or more than 50% of the floor time (for inpatient services) is spent providing counseling or coordination of care (C/CC). Providers typically rely on the “key components” (history, exam, medical decision-making) when documenting in the medical record, and they often misunderstand the use of time when selecting visit levels. ![]()
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