Primary Care Coding Alert

Question: Our family physician spends a lot of time discussing treatment options, imaging results, and other issues with patients. How should she document these activities to support coding E/M based on time? Arizona Subscriber Answer: 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 state, "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 add that the physician should document the total length of the encounter and "describe the counseling and/or activities to coordinate care." In the office or outpatient setting, you should count face-to-face time. In the hospital or in a nursing facility, you can count floor/unit time, according to both CPT® guidelines and Medicare's documentation guidelines. CPT® guidelines describe the encounter as a "physician/patient and/or family encounter." Example: [...]