Wiki Picking a level code-HELP

[sara0014]

Would you code this based off of time? I am stuck between two levels of service, but I feel that 99215 doesnt meet the medical decision making criteria. This is an established patient.

SUBJECTIVE: He presents self referred to discuss vasectomy. He is scheduling a follow up screening colonoscopy for October this year due to his strong family history of colorectal cancer. Today our focus was on the vasectomy. He had many questions about vasectomy. I spent 40 minutes with him discussing the procedure, alternatives, its risks, benefits and modalities of anesthesia. He is inclined towards a general anesthetic for personal anxiety reasons.


OBJECTIVE:
The patient's scrotum is normal. There are easily palpable vas-derentia. They are singular on each side. Testes normal bilaterally. Penis normal and circumcised.


ASSESSMENT/PLAN:
After our discussion, he chose to set up the colonoscopy but hold off on setting up a vasectomy until he can discuss options with his wife.


Exam time: 5 minutes Discussion about vasectomy 35 minutes.

 

[BPPasc]

You can not bill based on time due to the time statement being incomplete. In order to billed for time based coding the statement should go something as follows; 50 minutes was spent face to face with the patient and greater than 50% was spent discussing the risks, benefits and/or alternatives of a vascetomy

 

[Rita Bartholomew]

There are various ways to document time to indicate that more than 50% of the total time was spent on counseling/coordination of care. It seems clear that the time statement by the provider indicates that over 50% of the 40-minute visit was spent on c/cc, but perhaps I'm missing something. You need to know the total time of the visit (5+35=40) and you need to know if the majority of that time (>50% = majority) was spent on c/cc. I don't know how else you could interpret it.

 

[Tonyj]

There are various ways to document time to indicate that more than 50% of the total time was spent on counseling/coordination of care. It seems clear that the time statement by the provider indicates that over 50% of the 40-minute visit was spent on c/cc, but perhaps I'm missing something. You need to know the total time of the visit (5+35=40) and you need to know if the majority of that time (>50% = majority) was spent on c/cc. I don't know how else you could interpret it.

Agreed! Level 5 was met based on time.