Wiki Time based E/M

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beulastella

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Hi, someone help in the confusion in face to face time and counseling coordination of care in a visit. How should i code for "60 minutes was spent for this encounter, and more than half of that time was spent counseling the patient." Can any one suggest me to code it correctly for an established patient

Thanks,
Beula.S
 
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is what the patient was counseled on clearly found in the note (i.e. treatment options, plans for further care, etc)? if so then I would say you can support a 99215 based on time.
 
Hey. This statement should have "I spent" meaning the Doc and that this was "face to face" meaning he spent 60 min in the room with the pt not in his office and in the room.

Hope this helps! Happy end of month :eek:
 
beulastella said:
Hi, someone help in the confusion in face to face time and counseling coordination of care in a visit. How should i code for "60 minutes was spent for this encounter, and more than half of that time was spent counseling the patient." Can any one suggest me to code it correctly for an established patient

Thanks,
Beula.S
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In order to bill based on time and E/M, the physician must complete documentation of the E/M visit (CC, HPI, Exam, and MDM) he/she would then need to document the what, who, and time. They would need to state, "greater than 50% of this (total time) visit was spent counseling the (who) on (what)". The total time would then be your basis for your E/M code...as long as more than half was spent in counseling. The alternative to this would be if the patient was only there for counseling (an example would be such as with an oncologist who is discussing a new diagnosis of cancer, answering their questions, and discussing possible treatment options with a patient). Then the provider would need to go into greater detail documenting why the whole visit was spent in counseling, on what, and state that the total time spent in counseling. CMS has some good information on this as well as prolonged services, which sometimes can come into play in time based service coding depending on the time spent.

I hope this helps some :)
 
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