June 08, 2017 | | Comments 0
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Q&A: Best practices in time documentation

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Q: What is the best way to document time spent by physicians performing procedures? The CPT® codes state a vague time amount but the doctors struggle with this.

A: Time is always one of those really fun things, especially with E/M codes, because CPT puts a vague description of time amount requirements out there. So often, I end up having to query the physicians for time spend performing a procedure. I always like to have them explain the time. For example, he or she could say, “I spent 20 minutes of our 30-minute visit explaining how to properly use a new asthma inhaler.” That explains, how the physician met with the patient for 30 minutes and out of that time, used 20 minutes to explain how to use the new inhaler rather than just saying, “I spent 20 minutes discussing counseling or coordination of care.”

The other area that I always like to mention is sometimes time is best documented as “time in, time out.” Physicians are going to add that time up all day, especially if it’s a critical care patient. Physicians may want to get in the habit of documenting, “I walked in the patient’s room at 9:05 a.m. and we did our full thorough E/M exam and medical decision-making. I walked out of the patient’s room at 9:45 a.m.” So now coders have 40 minutes that a physician spent with the patient. And then a physician may go back into the room three hours later and document, “Patient was not responding well to those previous interventions. I now am back in the room at 11:18 a.m. and I spent from 11:18 a.m. until 1 p.m. with the patient and we’re still working on these interventions.” Then coders can add up all those time increments.

So to me, the best way I’ve found for providers to calculate E/M time is to document how many minutes of the total visit time that he or she spent counseling, doing coordination care, or what the provider talked to the patient about. But when I’m auditing inpatient records, I like to see the time in and time out and a bulk amount of time at the end of the day that I can add up to bill for that full-time increment and to know it’s all accounted for.

Editor’s Note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, answered this question during the HCPro webinar “Coding and Reporting Medical Necessity: Essentials for Coders and Other Healthcare Professionals.” This Q&A originally appeared in JustCoding

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Filed Under: ACDISCDI ProfessionClinical Documentation Improvement

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Linnea Archibald About the Author: Linnea Archibald is the CDI editor for the Association of Clinical Documentation Improvement Specialists (ACDIS). In this role, she helps out with the website, blog, social media, newsletter, and the CDI Journal. If you have any questions, feel free to email her.

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