Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist spends a lot of time discussing treatment options, imaging results, and other issues with patients. How should she document this to support coding E/M based on time?Arizona SubscriberAnswer: When counseling and/or coordination of care take up more than 50 percent of the encounter, and you choose to code based on time, CPT®'s E/M guidelines tell you "the extent of counseling and/or coordination of care must be documented in the medical record." Medicare's 1995 and 1997 E/M documentation guidelines (www.cms.gov/MLNEdWebGuide/25_EMDOC.asp) add that the physician should document the total length of the encounter, how much of the total time was spent in counseling and "describe the counseling and/or activities to coordinate care."Remember: In the office or outpatient setting, you should count only face-to-face time that the physician spends with the patient. In the hospital or in a nursing facility, you may count floor/unit time, according to both CPT® [...]