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Gastroenterology Coding Alert

Reader Question:

Base Level of E/M on Counseling/ Coordination Time

Published on Sun Nov 25, 2012

Question: If our gastroenterologist documents: "Time spent in the evaluation of the patient with mostly medical decision making time (two thirds) is 75 min," can I choose the E/M code based on time alone?   Nevada Subscriber Answer: No, you cannot code based on time with just the documentation you have mentioned. Here's why:  You should only code an E/M service based on time alone if at least 50 percent of the visit was spent on counseling or coordination of care. The documentation of the service is best if it specifically says "counseling" or "coordinate care" and the reason that time was needed. How it works:  According to this year's CPT® manual, you can use the code closest to the documented time. "If coding by time, pick the closest typical time," said Peter Hollmann, MD, during the "E/M, Vaccines, and Time-Based Codes" session at the CPT® and RBRVS 2011 Annual Symposium in Chicago. [...]
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