My employer has had an audit of charts and the insurance companies hired auditors have an issue with our billing by time documentation.

Our providers always follow the CMS guidelines and then refer to the assessment and plan or other documentation in the note for the content of counseling. Its pretty obvious what the counseling is about due to treatment options, diagnosis or complications. We are a pediatric practice so parents and caregivers come in and require lots of time for answering questions. We spend a lot of time addressing what the parent/caregiver has seen on the internet too. This seems to be a common way to document the counseling topics. However the large carrier that audited us said that’s not enough but would not give us an example of acceptable documentation for the content of counseling.

My question is has any other practice had a billing by time recoupment from a carrier? If so were you given any examples of acceptable documentation beyond the CMS documentation guidelines?

Thank you,
Louise