Wiki E&M Time Coding

[Cmarlh]

I have a dictation that I am looking at the codes out to a 99214, but the Dr spent 60 mins with this pt. Can we add the time to get a higher level? The time coding confuses me.

 

[mitchellde]

The physician must document total time spent with the patient in his note, and there must a counseling or coordination care issue as a reason for the extensive time or it is not upcodable. Does the physician document why the visit was so extensie? does he document total face to face time.

 

[Cmarlh]

Yes on both.

 

[dtlandry67]

You can document for time when greater than 50% of the visit was spent counseling the patient. The documentation needs to state the total time of the visit and how much of that time was spent in face-to-face counseling with the patient. For example, if the documentation stated "the total time of the visit was 60 min and 35 minutes was spent counseling the patient", then you can bill the 99215 based on time.