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50% Counceling & Coordination of Care

CodingAuditor

Contributor
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10
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What justifys the counceling statement for 50% counceling.
Does spent entire visit counceling on diabetes count? or should there be more documentation about details that were talked about.

I don't think it justifies, but my dcotors seem to think it does. Any feedback is greatly appreciated.

Thanks,
Dani
 

Lisa Bledsoe

True Blue
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Greeley, Colorado
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Coding according to counseling implies time, therefore he would need to state the total time of the visit; and if he spent the entire time of the visit counseling, as well as some kind of summarization of the counseling. A blanket statement "spent entire visit counseling on diabetes" definately would not cut it. He has to be more specific with the amount of time and what was discussed.
 

RebeccaWoodward*

True Blue
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3,126
Location
North Carolina
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Lisa's right...here's an example.

"A total of 15 minutes were spent face-to-face with the patient during this encounter and over half of that time was spent on counseling and coordination of care. We discussed in depth the importance of primary prevention of coronary disease with aggressive treatment of high cholesterol. I also educated the patient about lifestyle modifications which may improve blood pressure"


http://emuniversity.com/CodingBasedonTime.html
 
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