Ob-Gyn Coding Alert

Question: An increased number of peri-menopausal patients have presented in our office. The visit usually lasts for 45-60 minutes. Various testing and treatment options are ordered and presented. What is the best way to code this visit?

New Jersey Subscriber

Answer: The key to accurately coding and being paid for visits like this is the physicians documentation in the medical record. Whenever counseling of the patient and/or coordinating care dominates the visit (more than 50 percent) then time can be used as the determining factor when selecting the evaluation and management (E/M) code. It is critical that the physician document the amount of time spent during the encounter and provide written details in the patients medical record as to what was discussed. Time should be documented as the total number of minutes spent in the encounter, or you should include the start and stop times in the actual documentation.