Providers typically rely on the “key components” (history, exam, medical decision-making) when documenting in the medical record, and they often misunderstand the use of time when selecting visit levels. Sometimes providers may report a lower service level than warranted because they didn’t feel that they spent the required amount of time with the patient; however, the duration of the visit is an ancillary factor and does not control the level of service to be billed unless more than 50% of the face-to-face time (for non-inpatient services) or more than 50% of the floor time (for inpatient services) is spent providing counseling or coordination of care (C/CC).1 In these instances, providers may choose to document only a brief history and exam, or none at all. They should update the medical decision-making based on the discussion.
Explore this issue:May 2015
Duration of Counseling and/or Coordination of Care
Time is not used for visit level selection if C/CC is minimal (<50%) or absent from the patient encounter. For inpatient services, total visit time is identified as provider face-to-face time (i.e., at the bedside) combined with time spent on the patient’s unit/floor performing services that are directly related to that patient, such as reviewing data, obtaining relevant patient information, and discussing the case with other involved healthcare providers.
Time associated with activities performed in locations other than the patient’s unit/floor (e.g. reviewing current results or images from the physician’s office) is not allowable in calculating the total visit time. Time associated with teaching students/interns is also excluded, because this doesn’t reflect patient care activities. Once the provider documents all services rendered on a given calendar date, the provider selects the visit level that corresponds with the cumulative visit time documented in the chart (see Tables 1 and 2).