EM Coding Alert

Pay attention to notes or risk missing counseling exception opportunities.

You’d better have your ducks in a row if you want to code an E/M service using the counseling exception.

Example: You’re a coder looking at the notes for an E/M service. What are the key terms you can look for in the documentation that might indicate a counseling exception E/M?

Use this expert advice to sift through terms that might lead you to using the counseling exception and striking E/M gold.

Record Must Reflect Extra Time

When considering the counseling exception, “the first requirement is that time must be documented in the record,” explains Melanie Witt, RN, CPC, MA, an independent coding expert based out of Guadalupita, N.M.

According to Witt, the provider must document not only the total time spent with the patient, but indicate in minutes or as a percentage how much of this time was spent on counseling. 

The documentation must also contain the content of the counseling or coordination of care, Witt continues. “That [E/M] note should be commensurate with the amount of time claimed. For instance, if the physician documents 15 total minutes with more than 50 percent of this time spent on counseling, the note describing would not need to be lengthy, but as the total face-to-face (and counseling time) increases, the documentation must be much more detailed.”