Cardiology Coding Alert

Question: Can you explain when to code E/M based on time for counseling?

New Mexico Subscriber

Answer: The main rule you need to know is that counseling, coordination of care, or a combination of the two must take up more than 50 percent of the encounter for you to consider time to be the controlling factor in your code choice.

Carefully read the E/M guidelines, which get into technicalities like defining time as “face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility.”

The medical record should include the total time the provider spent with the patient and carefully note either the precise number of minutes devoted to counseling or the percentage of the total time spent on counseling. 

You also need to see documentation about the content of the counseling. Experts advise that the more time the provider notes she spent in counseling, the longer the note about content should be. 

Bonus tip: E/M guidelines define counseling this way. “Counseling is a discussion with a patient and/or family concerning one or more of the following areas:

• Diagnostic results, impressions, and/or recommended diagnostic studies
• Prognosis
• Risks and benefits of management (treatment) options
• Instructions for management (treatment) and/or follow-up
• Importance of compliance with chosen management (treatment) options
• Risk factor reduction
• Patient and family education.”