August 28 Tip - Time-Based Services

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August 28 Tip - Time-Based Services

Postby lori » Fri Aug 28, 2015 6:50 pm

Hi,
I'm struggling a bit with the interpretation of the quoted CMS resource. I read Section 30.6.1 C from Chapter 12 of the Medicare Claims Processing Manual, and I don't see how it conveys that the overall MDM level for the given visit must directly correspond with the MDM associated with the specific time-based E/M level (such as requiring moderate overall MDM for a time-based 99214). In the context of the entire Section C, CMS is talking about how a history and exam are not required for these cases, so CMS makes a couple of references to the relevance of time spent in counseling/coordination of care and medical decision making. While I concede that Medicare clearly expects documentation of the medical decision making in these cases (due to the medical necessity aspect), I don't see clear guidance from CMS that the MDM of the given visit must correspond with the MDM of the time-based E/M level. Perhaps this is a gray area that is open to interpretation.
lori
 
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Re: August 28 Tip - Time-Based Services

Postby admin » Wed Sep 02, 2015 2:54 pm

I agree that there are always going to be multiple interpretations in certain situations. CMS states:

"Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim."

We know that medical necessity is the over-aching determining factor in E&M code selection. We feel that placing the focus on MDM (even in time based coding scenarios) mitigates compliance risk. Plain and simple. If providers feel that they can talk slower to reach higher time based coding thresholds that could be a risky approach. That's really the point we are making...for example, 99215 is not going to be supported for a patient with established chronic conditions that do not pose threat to the patient's life of bodily function even if the provider spends 40 minutes with that patient.
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Re: August 28 Tip - Time-Based Services

Postby lori » Tue Sep 08, 2015 2:52 pm

Thank you for the response. That helps me better understand the perspective. Have a great day!
lori
 
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Joined: Fri Aug 03, 2012 2:22 pm


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