May 7, 2015
Our surgeon saw a patient in the office following a shoulder MRI. In the visit, the surgeon documented, “I had a very long face-to-face discussion with the patient today regarding their shoulder MRI. I spent over 20 minutes in the exam room discussing the results of the scan, reviewing the MRI with the patient, discussing the findings, pathology of the disease process and discussing operative versus non operative management. The patient has chosen to start first with physical therapy but understands that due to the pathology at this time, surgery may be required in the future.” The surgeon has stated that this visit should be based on time because there was no medical necessity to repeat all the history and exam information as nothing had changed since the prior visit. In looking at the note, I do not believe the documentation requirements are met to select a code based on time. Can you please advise?
Thanks for reaching out. Your question is a great question and the scenario an excellent one to educate the surgeon on closing the documentation gaps required when counseling and coordination are the exceptions to selecting a code based on the three key components. To report a service based on time, three key elements must be documented: 1) the total face-to-face time between the surgeon and, in this case, and the patient. It is not the time the patient is in the office, but the total face-to-face time only. 2) that greater than 50% of the time (or the specific amount of time equaling a unit greater than 50%) was spent counseling or coordinating care and 3) the nature of the discussion or work must be documented. In your scenario, two of the three elements are present, but what is missing is the statement related to the amount of the face-to-face time that was spent with the patient. Without all three elements, the code selection reverts to the three key components.