tci ED Coding & Reimbursement Alert - 2009 Issue 10

Include Solid Documentation to Justify 'Discussion' Time

Code interactions with caregiver separately -- provided the physician directly discusses treatment options. Experts remind us that sometimes, you can count discussions with the patient's family, caregiver, or authorities toward overall critical care time. When you do, however, you'd better be sure it's wellnoted in the medical record, or you can expect payer scrutiny. Count Hx, Tx Time "Time spent obtaining history or discussing the patient's treatment options is not considered a separate service and should be included in the physician's total critical care time," relays Greer Contreras, CPC, senior director of coding for Marina Medical Billing Service...

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