tci E/M Coding Alert - 2019 Issue 1

Reader Question: Keep Time on Your Side with This E/M Documentation Tip

Question: We have a provider who sees a lot of pediatric patients with their parents. The parents ask a lot of questions, and the provider almost exclusively bills by time. We know that we must document the total time of the visit, as well as the time spent counseling/coordinating care, and a note about what was discussed. But our physician only documents the total time and doesn’t say what he discussed. Can we still bill this type of visit based on time? New York Subscriber Answer: Unfortunately, that documentation won’t work for most insurers. CPT® says in...

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