Page 1 of 1

Time statement- Medical Necessity

Posted: Tue Jan 08, 2019 5:12 pm
by janinemarie86
Hello,

For EMs coding based on time statements: do the EM elements need to support the level of service as described based on the average time associated with the code?

What advice would you give to providers that represent their work by time for higher levels of service, although the medical necessity of the visit could be called into question due to low/lower severity conditions?

Re: Time statement- Medical Necessity

Posted: Thu Jan 10, 2019 8:59 am
by shutchins
Whether you are coding the documentation based on time or on the key components, medical necessity is still the overarching criterion. If the provider documents they spent 45 minutes with a patient that presents with a chronic stable problem, the medical necessity still only supports a level three visit.

Now that we covered the medical necessity piece, time is only used to determine the level of service when the visit is dominated by counselling and coordination of care. If this is the case, CMS requires that the MDM also support the level of service that is reported by time. If the provider documented 45 minutes, but the MDM is low, it is a level three visit. (assuming of course that the MN also supports level 3) If the documentation does not support that the visit was dominated by counselling and coordination of care, you assign the level of service supported by documentation using the key components, not the time.
Your question has been answered by: Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA