Wiki 99215???

[HBULLOCK]

We have a patient who came in for birth control selection who also has abd pain, dizziness, and sti exposure. When checking the documentation i don't believe the mdm is high though dr wants to code 99215 since she spent 1 hour and 10 min with patient. I think i should charge 99214 w/99354 (prolonged serv). Any thoughts??? Thanks

 

[Belinda Frisch]

Time

The only way the MD could code based solely on time is if the more than 50% of the encounter was spent "counseling and/or coordinating care". The documentation must reflect the total time spent and the duration and content of the counseling proving that it was more than 50%. Otherwise, yes, you'd have to go to the prolonged services codes in addition to the E/M.