Ob-Gyn Coding Alert

Question: If the ob-gyn 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 SubscriberAnswer: No, you cannot code based on time with just the documentation you have mentioned. Medical decision making does not qualify as one of the criteria for choosing time.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, and this fact must be noted in the documentation.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 this [...]