Q: Can we count resident’s time?
A: No. Teaching physician rules haven’t changed. Resident time is not billable.
Q: Do you need to document exactly how you spent your time with the patient, or just the total minutes?
A: It is recommended to document total minutes plus brief summary to support that time.
Q: Can we count time spent the day before the visit?
A: No, the guidelines specifically state that the total time is only time spent on the date of the visit.
Q: When one of our providers has documented that they placed a referral (e.g. physical therapy, a specialist, etc.). How would that fit into the scoring of MDM? Our provider did not document the time of the encounter so I can’t pick up a code based on Time. The presenting problem is Low, and not really sure about the risk piece of this encounter and whether it is Low or Moderate so a little stumped. Wondering if you would be able to suggest something or direct me on where to dig for more information?
A: A common example is a provider takes a look at an x-ray film – the provider is not billing for the professional interpretation of this film, because the radiologist will do the official read. In the documentation the provider documents they independently looked at the xray and gives their opinion. This is also common with EKG tracings, where the provider will give their impression, but a cardiologist bills for the final professional interpretation.
Shea Lunt, RHIA, CPC, CPMA, PMP
Shea is a consultant for The Haugen Consulting Group with 11 years of health care industry experience. Shea has experience working on the professional fee side of coding, auditing, education and compliance serving coders and physicians.
She earned a bachelor’s degree in health information management and a master’s degree in health services administration from the University of Kansas. Shea is a Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA) and a Project Management Professional (PMP).
Shea, her husband, and their daughters, call the wide-open spaces of central Kansas home.