99215 based on time

mburgett

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Falkville, AL
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I have a note that states "Professional Services - Counseling Summary: This was a 45 minute visit with greater than 50% of that time spent counseling the patient. Counseling included treatment options, current condition, and New onset/severe major depression. The patient was interactive, and asked questions".

The criteria for a level four E/M is there, but this is a level I do not see often enough to feel comfortable to proceed. Can anyone assist with my dilemma? Thanks in advance!
 

Chelle-Lynn

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The documentation for time must meet the following:

- Document Total Time (face to face)
- 50% or more was spent counseling or educating the patient
- What the counseling or education was in reference too

Your provider met these requirements so the use of 99215 would be correct. I would suggest that the provider use the term "face-to-face time" for future documentation, but otherwise it appears good.
 
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