Pain Management Coding Alert

Question: I’m confused about coding evaluation and management (E/M) services by time. Do we have to document the exact amount of time spent on counseling and coordination of care, and do we have to document how much face-to-face time the physician spends with the patient?

Georgia Subscriber

Answer: To bill an E/M visit based on time, you must document that the majority of the time was spent in counseling and coordination of care. For the office/outpatient setting, only face-to-face time counts toward the total time spent, but for the inpatient setting, you should also count time spent on the unit focused on the patient.

With that understanding, you can see that the answer in the office setting is “yes” for your second question; you must document how much face-to-face time the physician spends with the patient.

Regarding the first question, you do not have to document the exact amount of time spent on counseling and coordination of care. But your documentation must state that the physician spent more than 50 percent of the visit in counseling and coordination of care. Another way to document that in the report is to state that the physician spent “more than half the time,” or “the majority of the time” in counseling and coordination of care. 

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