Forum - Questions & Answers

Jan 3rd, 2015 - mselke 1 

coding for new patient based on time alone

Can you code a new patient visit based solely on time alone if All 3 elements have not been met ( patient seen for travel counseling visit with time spent counseling 30 minutes, warranting a 99203 based on time, but Comprehensive HPI, PMSH, ROS and Comprehensive PE not documented).

Jan 7th, 2015 -

re: coding for new patient based on time alone

No HPI documentation at all? CC? Can you bill an Office Visit with out a Cheif Complaint?

For an office visit billing for time only:
E/M guidelines allow physicians to use TIME as the controlling factor to determine the level of care in certain circumstances. In these instances, the physician MUST spend the entire allotted time face-to-face with the patient AND at least HALF of that time must be used for “counseling and coordination of care.” If you choose to code based on time, you MUST record the duration of the encounter in the record, AND also state that over half the time was spent on counseling and coordination of care. In addition, the nature of the counseling and coordination of care must be documented.

Jan 7th, 2015 - podcoder 20 

re: coding for new patient based on time alone

No, I would not bill more than a 99202.

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