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msingh23

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Need some advise how this can be bill if any...
New patient visit, no HPI,ROS or Exam. Sports meds Dr. spent 30 minutes on counseling patient with mom per their concern on some blood result. Pt plays sports and wants to contiuned. Patient was referred to see nutritionist. I will like to know if this can justify to bill as counseling 99203.
Thanks
 
The CPT guidelines state:
When counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family (face-to-face time in the office or outpatient or floor/unit time in the hospital or nursing facility), then TIME shall be considered the key or controlling factor to qualify for the level of service.
30 minutes supports a 99203.
We make our providers specifically document the total time with the patient, in minutes, and then state, in minute,s how much time was spent in counseling.
 
Thanks for your response...
I wanted to know in this situation when the entire visit was counseling with no documentaion of HPI, ROS, Exam because none was done is this was ok... Dr did document total visit time in minute same time in minutes for counseling.
Thanks
 
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