Oncology & Hematology Coding Alert

Question: The physician states that "more than 40 minutes was spent counseling the patient and her husband" and no physical was done. Is it OK to bill this with E/M based on time of 40 minutes even though it does not state 40 minutes with over 50 percent of time spent counseling? Does the 50 percent language always need to be included in the time statement?

Codify Member

Answer: The documentation doesn't have to include "more than 50 percent," but it does need to include enough information to calculate that counseling and coordination of care took up more than 50 percent of the visit.

For example: In this case, the physician could have documented that the total time of the visit was 60 minutes with 40 minutes spent in counseling the patient with her husband present.