Download Documentation for Time Based Codes:

Documentation for Time Based Codes:
Documentation for Time Based Codes
When counseling and/or coordination of care makes up more than 50% of the time the
physician spends with the patient in the office, then the level of care can be selected
solely on the basis of the time spent.
Level 1
Level 2
Level 3
Level 4
Level 5
New patient visit
10 min
20 min
30 min
45 min
60 min
Consultation
15 min
30 min
40 min
60 min
80 min
Established patient visit
5 min
10 min
15 min
25 min
40 min
Visit code selection is based on the total face-to-face encounter time between physician
and patient, not just the counseling time.
Only the doctor’s FACE TO FACE PATIENT time counts. Time spent by other staff
cannot be included.
Time spent coordinating the patient’s care after the patient has left the office cannot be
included.
The medical record should document:
-
Total time spent by the physician with the patient
Time spent counseling
A description of the coordination of care or counseling provided
Established Patient Example: “I spent 15minutes (total time 25 minutes) discussing
diagnosis of hypertension, prognosis and treatment alternatives. Answered patient’s
many questions concerning results of diagnostic tests and new medications. Discussed
and gave pt. information on diet. Stressed importance of compliance and follow-up with
above. ”
Above example would be a 99214-Established patient level 4.
New Patient Example: Spent 30 minutes of 35-minute visit discussing with new OB
transfer patient our practice style. Answered many questions related to care and followup provided by this practice. Gave patient information on pregnancy and delivery.
Above example would be a 99203—New patient level 3.
Counseling may include one or more of the following:
-
Diagnostic results, impressions and/or recommended diagnostic studies
Prognosis
Risks and benefits of management/treatment options
Instructions for management and/or follow-up
Importance of compliance with chosen management/treatment options
Risk factor reduction
Patient and family education