While many view the process of documenting for services billed to the Medical Service Plan (MSP) as time consuming, it is one of the most important nonclinical requirements of a physician’s practice. The Billing Integrity Program will base their audit decisions primarily on the degree of documentation in a medical record.

Recent audits have revealed that time-based fees are not always recorded correctly, as required by the payment schedule. Some fee items require times to be entered in the patient’s chart, some require times to be entered in the billing claim, and some require entries in both the chart and claim. If the required information is not recorded correctly, physicians may be vulnerable in an audit.

Below are a few example scenarios:
•    If you bill a call-out fee or operative surcharge, the payment schedule requires start and end times for the service to be recorded in your claim. Additionally, the payment varies depending on the time of the call-out; therefore, this should be recorded in your consultation or operative reports as well. 
•    If you bill a prolonged-counseling-visit fee, you must also follow the noted requirements for the fee that are listed in the payment schedule. For GP counseling fees, this requires recording the start and end time of the visit in both the billing claim and the patient’s record, as the fee has a minimum 20-minute duration requirement.
•    If you bill for a lysis of adhesions, which is a surgical time-based fee, you should also record the start and end time of the lysis procedure in both the operative report and the billing claim. 

Having little or no documentation in your clinical records to support your time-based fees would be interpreted as having incomplete records, and the associated claims would be considered in error if you were audited.
—Lorne Verhulst, MD
Chair, Patterns of Practice Committee

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This article is the opinion of the Patterns of Practice Committee and has not been peer reviewed by the BCMJ Editorial Board. For further information contact Juanita Grant, manager, audit and billing, Physician and External Affairs, at 604 638-2829 or jgrant@doctorsofbc.ca [9].