Nov 1st, 2016 - gatorcoder2
I am Auditing a record for a Behavioral Health provider, the practice lists all dates of service on 1 document. The 1st visit, the testing visits and the follow-up. This takes place over several weeks or months. There is only one signature at the end of the document. It is noted that a person conducted the testing (not the provider) in "2-3 hours" in that location but this person does not say exact time and does not sign the note? They list all the dates of services on the record. They bill for each as they are completed? Like a new patient, the 96116 and a 99214 or 99215 follow-up? I believe each note should stand on its own with a signature and the time needs to be noted to what it was 2 hours or 3 hours... other than the many pages of testing there is not a statement to sate they spent face to face etc... any thoughts or help? I have not seen records they combine into one long note with multiple dates of service?
Nov 8th, 2016 - slackcoder 55
I would not be too concerned about having only one document to support charges for multiple dates of service.
However 96116 is a per hour code so the provider needs to document the face to face time and time interpreting test results and preparing the report for each date of service.
96116 includes face to face and interpreting test results and preparation of the code.