For inpatient services: considering unit/floor time for services, does the focus of the service have to be dominated by counseling/coordination of care, like in outpatient services?
For example: Greater than 50% of the 45 minute service was spent at the bedside spent in direct patient care.
It does not state that there was counseling/coordination of care, just that time was spent in patient care.
Is this acceptable?
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In order to bill by time, more than 50% of the encounter needs to focus on counseling/coordination of care. For any typical inpatient service, it is expected that the majority of the visit would be face-to-face at the bedside.
Depending on the complexity of the visit, this might be eligible for prolonged services as documented, but remember that in order to bill any time-based E/M codes, there needs to be some type of narrative as to the reason for the unusual length of service.
Your Question has been answered by:
J. Paul Spencer, CPC, COC
Senior Compliance Consultant