# coding based on time



## LORA CRAWFORD (Jan 4, 2010)

If a doctor states in his note that total time of the visit was 1 hour and 45 minutes was spent in counseling could you bill a level 5 for over 50% of the time was in counseling?

thanks for any feedback. 
Lora


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## alumnieib (Jan 4, 2010)

Yes you can, but the documentation must clearly list everything that was discussed.


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## mitchellde (Jan 4, 2010)

It depends on the level of visit met by the 3 key components.  If this were a new patient level 4 then no it could not be up coded as a level 4 says 45  minutes is the assesment time and subtracted from the total time spent leaves only 15 minutes which is not 50% if it is an established patient then yes it is a level 5 or a visit level plus prolonged time.  So if this were a 99214 then you would be able to append 99354 as well.  There is never an absolute in coding E&M it is all case by case and based on the documentation.


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## LORA CRAWFORD (Jan 4, 2010)

Thank you is there anywhere that I can get that in writing?


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## alumnieib (Jan 4, 2010)

I agree it does depend on documentation however:

CPT states, "When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services." This means that time alone can be used to select a level of care, regardless of the extent of the history, exam or the medical decision making, if the majority of the encounter involves counseling or coordination of care. For E/M services, counseling may include a discussion of test results, diagnostic or treatment recommendations, prognosis, risks and benefits of management options, instructions, education, compliance or risk-factor reduction.

Therefore, this encounter was one hour - 45 minutes( over 50%) was spent couseling or coordinating care, therefore, if this was an established patient visit, yes 99215 can be used.  Documentation must be very clear on what was discussed.


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