The physician or qualified health professional must report 15 minutes of prolonged service on the day of the encounter for each unit of service. But be aware that when you should start counting the prolonged time will vary based on whether you’re billing a private payer that uses the CPT code or Medicare or other payer that uses the HCPCS code. Use these decision trees and chart to understand how the guidelines impact the way you code.
Clinical documentation, Health information management, Training
Download this organized graphic of AHIMA’s Standards of Ethical Coding to help support yourself as you assign and sequence codes correctly and in a compliant fashion.
One key question on many coders’ minds: Can a clinician count an independent interpretation when he or she ordered the test? Use this chart to find out.
To code office/outpatient visits based on time, add the minutes a physician or qualified healthcare professional spends on a variety of activities, including the time it takes them to update the patient’s medical record. To accurately document and code office visits with time, it’s important to understand the activities that count toward time. Because it is unlikely that every visit will include every activity, providers may overlook activities that they rarely perform.
The following illustration will help providers not miss out on countable activities.
A “discussion of management or test interpretation” can earn a moderate or high score under the data review element of an E/M office visit. But before you give the billing practitioner credit for a discussion, make sure the documentation shows that it met the definition of a discussion.
Use the following illustrated guide on discussions to train staff.
Health information management, Hospital inpatient, Physician queries
The following sample policy regarding query escalation and resolution addresses the specific timing expectations for query responses, how coders should communicate with CDI staff and physician advisors, and what circumstances might warrant raising an unanswered query to the attention of a CDI or HIM manager, physician advisor, or higher-level administrator.
