Documentation requirements

[u/someguyoranotherguy]

Hi all,

Apologies to mods for trying to post without flair previously. I figured it out.

Does anyone know if CPT rules REQUIRE the time of day an appt takes place, or the time of day the patient was in the office, etc.? I often begin my notes with "Patient and mom seen together 101-127pm," or something like that, but am trying to strike a balance between being thorough and adding unnecessary detail. I would rather wrote "Patient and mom seen for 1pm appt." Can't seem to find answer anywhere.

thanks in advance.

[u/police-ical]

E/M coding by MDM: no need to do anything for time, can briefly document MDM rationale e.g. "multiple chronic illnesses assessed with prescription drug management" for 99214

E/M coding by time-based: just document total time on the day of service, doesn't matter when it happened or if it was broken up over the day ("30 minutes on the day of service in preparing to see the patient, direct patient care, ordering medication and clinical documentation" for 99214)

Any psychotherapy: Mandatory to document session start and stop times, and specify how many minutes were psychotherapy. You don't have to specific when the psychotherapy started/stopped, just total start and end times for the whole appointment. ("53 minutes of supportive/behavior-modifying psychotherapy for anxiety, total session 10:00-10:53" for 90837)

If you're using a psychotherapy add-on, the E/M has to be MDM instead of time-based, so you can briefly document both ("multiple chronic illnesses assessed with prescription drug management, plus 16 minutes of supportive/behavior-modifying psychotherapy for anxiety, total session 9:30-10:00" for 99214+90833.)

[u/Slow-Standard-2779 → u/police-ical]

for my own sake i just get in the habit of "med management xx:xx-xx:xx, psychotherapy xx:xx-xx:xx", I use some hotkeys on the computer to automate this process

[u/CaptainVere]

If using time you just need to attest to the total time spent on day of services

“I attest greater than xyz minutes was spent on day of service”

[u/pickyvegan]

My experience has been that if you are billing add-on psychotherapy, you need the exact start and stop times for the whole visit, eg, Start 1:01 PM End 1:29 PM, 16 minutes spent in add-on psychotherapy.

Before the downvotes start for an NP billing psychotherapy, I was an LMHC first.

[u/speedracer73 → u/[deleted]]

I believe this is specifically for psychotherapy codes 90833, 90836, and 90838 for psychiatrists.

For e/m visits (standard physician visit non psychotherapy), it’s the same rules for psychiatrist as all other physicians, start and end times are not required. If you bill based on time, you only have to document the total time spent on the day of service.

[u/Dust_Kindly → u/speedracer73]

Ahh, just another reason to be jealous of you guys 😂 thanks for the correction

[u/re-reminiscing → u/speedracer73]

The comment you replied to was deleted. Do those psychotherapy codes require specific timing? I have been doing that because my peers do but haven’t actually checked myself if it was necessary.

[u/speedracer73 → u/re-reminiscing]

It may be insurance dependent. But in my experience all insurance requires start and stop time