When counseling or coordination of care dominates the encounter between the physician and the patient and his or her family, time may be considered the controlling factor to qualify for a particular level of E/M coding. Here are some pointers that rheumatology practices should review to successfully use time in the billing process:
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- More than 50% of the time you are with a patient must be spent on counseling or coordination of care (e.g., diet, exercise routines, and reviewing medication interactions);
- You cannot count time spent by ancillary service providers;
- You must document the actual amount of time spent with patient; and
- The description of what you discussed must sound plausible for the amount of time you claim.
Keep in mind that this also includes time spent with other individuals that have assumed responsibility for the care of the patient, including foster parents, persons or organizations assuming care for a patient, or a legal guardian. It is also very important that the extent of the counseling and coordination of care is documented in the medical record in a separate paragraph.