What does the provider need to include when billing based on time?

When billing based on time, the provider must include the total time spent on the patient's care as well as specific details about the counseling that was provided during the visit. This is essential because the coding guidelines stipulate that time can be used as a key factor in determining the level of service being billed, particularly for certain types of visits, like consultations or when the physician spends more than half of the visit time in counseling or coordination of care.

The total time documented should encompass not only direct face-to-face interaction with the patient but also any other time spent on their behalf, including reviewing charts, conducting phone calls, or coordinating services with other providers. Additionally, detailing the counseling offered is crucial, as it provides justification for the time billed under evaluation and management codes. This level of detail supports the billing and ensures compliance with Medicare and other payers’ requirements.

Including only the total time without the context of what was discussed during counseling would not meet the coding criteria and might lead to claim denial or audit complications. Therefore, providing both the total time and the specifics of the counseling is key to accurate and defensible billing practices.