Counseling code?

[veloso]

I have a follow-up visit (99213) and the Provider document: I spent 15 minutes counseling pt regarding antiviral treatment options,how will I could this?
1.To upcode to 99214?
or
2.To add the 99401(counseling) to the visit 99213?

THANKS.

[gailmc]

When determining a level of service, you can use the key components (HPI, Exam, and MDM) or time. For your example, you should not upcode to 99214 since the time documented was only 15 minutes. If the documentation for the chief complaint meets a 99213 and then the provider documented an additional 15 minutes of counseling, you could use the 99401. If the provider documented an additional 30 minutes, you could also use the prolonged service code 99354.

[FTessaBartels]

I think your physician is thinking that he can code based on counseling/coordination of care.
In order to do this your documentation MUST include the following:
1. Total time spent face-to-face with patient for the ENTIRE encounter
2. Amount of time spent in counseling coordination of care - must be MORE than 50% of total time.
3. Brief statement of what the counseling/coordination of care included.

You physician has stated he spent "15 minutes counseling patient regarding antiviral treatment options." This would satisfy items 2 and 3 IF ... Big Red IF ... the physician had also stated the grand total time spent with the patient, and the counseling time was more than 50% of the total. (I.e. total time between 15 minutes and 29 minutes inclusive)

THEN, you would code the entire encounter based on total time spent:
total time 15-20 minutes = 99213
total time 21-29 minutes = 99214

Hope that helps.

F Tessa Bartels, CPC, CEMC

[veloso]

The Provider just want to QUERY if that documentation is acceptable to support the 99401 without the start and stop time as an additional to the visit code 99213.
Thanks.