eharn
New
I would like clarification on what needs to be documented in the note to qualify for an office visit based on time.
The CPT guidelines state that when counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family, then time shall be considered the key or controlling factor to qualify for a particular level of E/M service. It also states the extent of counseling and/or coordination of care must be documented in the medical record.
I have an established patient with breast cancer, on chemotherapy, that is being seen to go over results of testing and to established a future plan for treatment. This patient's note is entirely based on counseling and coordination of care, and the documentation includes information regarding the discussion and a plan for treatment.
Since this visit doesn?t have a typical History/Exam/MDM, what would you have to have to qualify other than the amount of time spent?
Can you tell me if any of the below examples qualify or not?
1. A total of 15 minutes was spent with the patient.
2. A total of 15 minutes was spent with the patient going over results of recent testing and options available.
3. I spent 15 minutes with the patient counseling her on the recent testing results and options. Greater than 50% of this visit was spent in counseling and coordination of care.
The CPT guidelines state that when counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family, then time shall be considered the key or controlling factor to qualify for a particular level of E/M service. It also states the extent of counseling and/or coordination of care must be documented in the medical record.
I have an established patient with breast cancer, on chemotherapy, that is being seen to go over results of testing and to established a future plan for treatment. This patient's note is entirely based on counseling and coordination of care, and the documentation includes information regarding the discussion and a plan for treatment.
Since this visit doesn?t have a typical History/Exam/MDM, what would you have to have to qualify other than the amount of time spent?
Can you tell me if any of the below examples qualify or not?
1. A total of 15 minutes was spent with the patient.
2. A total of 15 minutes was spent with the patient going over results of recent testing and options available.
3. I spent 15 minutes with the patient counseling her on the recent testing results and options. Greater than 50% of this visit was spent in counseling and coordination of care.