Wiki E/m question

[jeaner54175@yahoo.com]

I have been struggling with this and I hope someone can clarify it for me. If a provider sees a patient for a sinus condition and the documentation supports E/M code 99213 but the provider puts in her dictation that she spent 30 minutes with the patient providing counseling during most of the visit. She codes it with 99214; does the extra time spent counseling constitute using the 99214 or do you go by the documentations and use modifier 25?

Thank you,
Lisa Nieft, CPC- A

 

[mitchellde]

I have been struggling with this and I hope someone can clarify it for me. If a provider sees a patient for a sinus condition and the documentation supports E/M code 99213 but the provider puts in her dictation that she spent 30 minutes with the patient providing counseling during most of the visit. She codes it with 99214; does the extra time spent counseling constitute using the 99214 or do you go by the documentations and use modifier 25?

Thank you,
Lisa Nieft, CPC- A

The provider needs to document the entire time of the encounter not just the counseling portion. If 30 minutes is the only time documented for a 99213 level then no you cannot up code for counseling as it must be more than 50% spent in counseling and this would not meet that criteria. In addition the counseling must be relevant and therefore the substance of the counseling must also be documented. Without the note it is hard to tell, however sinusitis does not usually require a significant counseling session.