I was just wondering what the consensus is on whether this scenario would be allowable for billing based off of time. The patient is being seen for a subsequent inpatient visit. The doctor documents the interval history, an exam, and a lengthy assessment and plan. She then goes on to document this:
Per caring team, asked to clarify details of code status – extensive discussion with pt’s daughters – in case of code/cardiac arrest – No CPR, No intubation. Ok med’s (chemical code) and shock/defibrillation. In case of respiratory distress without code/cardiac arrest – ok to intubate short term for reversible conditions.
Verified with team – correct orders – should be DNR with above limits.
Awaiting transfer SDU.
Discharge planing SNF – care coordinator input.
Face to face discussion/coordination of care 40 min.
So here the documentation shows that the face to face discussion/coordination of care was 40 minutes, which is shown to be separate from the rest of the visit and that the whole 40 minutes was spent in face to face discussion/coordination of care. Would this documentation be acceptable to bill based off of time?