In my recent columns, I addressed documentation guidelines with respect to the three key components: history, exam, and medical decision-making. However, time is considered the fourth key component.
Time-based billing places significant emphasis on the duration of the hospitalist-patient encounter more so than the detail or quality of the documentation. This month, I’ll focus on the guidelines for reporting inpatient hospital services based on time.
Hospitalists try to make their rounds as efficient as possible while still upholding a high standard of care. It is not unusual for a patient encounter to vary from the norm of updating the history, performing the necessary exam, and implementing the plan.
In fact, hospitalists often counsel patients with newly diagnosed conditions or when treatment options seem extensive and complicated. Based on these circumstances, physicians can document only a brief history and exam or none at all, since the bulk of the encounter focuses on medical decision-making, counseling, and coordination of care. Despite the minimal documentation compared with other physician services, it still is possible to report something more than the lowest service level (e.g., subsequent hospital care, 99231).
To use time as the determining factor for the visit level, more than 50% of the total visit time must involve counseling/coordination of care. The total visit time encompasses both the face-to-face time spent with the patient at the bedside and the additional time spent on the unit/floor reviewing data, obtaining relevant patient information, and discussing the case with other involved healthcare providers. Physicians providing care in academic settings cannot contribute teaching time toward the total visit time. Further, only the attending physician’s time counts.
Hospitalists must document events during the patient encounter. There may be little or no history and an exam and counseling may dominate the entire visit.
Physicians must document both the counseling/coordination of care time and total visit time. The format may vary: “Total visit time = 25 minutes; more than 50% spent counseling/coordinating care,” or “20 of 25 minutes spent counseling/coordinating care.” Any given payer may prefer one documentation style over another. It always is best to query payers and review their documentation standards to determine the local preference.
In addition to the time, physicians must document the medical decision-making and details of the counseling/coordination of care. For example, patients with newly diagnosed diabetes need to be educated about their condition, lifestyle, and medication requirements. Physicians should include information regarding these factors in their progress notes as necessary.