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Wiki 99215???

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HBULLOCK

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SALEM NH
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We have a patient who came in for birth control selection who also has abd pain, dizziness, and sti exposure. When checking the documentation i don't believe the mdm is high though dr wants to code 99215 since she spent 1 hour and 10 min with patient. I think i should charge 99214 w/99354 (prolonged serv). Any thoughts??? Thanks
 
Time

The only way the MD could code based solely on time is if the more than 50% of the encounter was spent "counseling and/or coordinating care". The documentation must reflect the total time spent and the duration and content of the counseling proving that it was more than 50%. Otherwise, yes, you'd have to go to the prolonged services codes in addition to the E/M.
 
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