Wiki Billing for counseling only no PE, ROS>>>?E/M

[dottymiller]

Hi I am new to Oncology Billing, Anyone have input on this topic:

Patient was seen for D75.81 Myelofibrosis and E 86.9 Volume depletion, unspec. The MD provided counseling to review her Bone Marrow Biopsy and discuss the nature of her disease, being incurable, etc. He spent 30 minutes..

Can we bill the appropriate E/M level without a PE, ROS?

Should we have a "CC" like " pt here to dicuss BMBX"?

Document total visit time and couseling time.. ie.."60 minutes with 50 minutes couseling"?

MD needs to document "significant detail" to support counseling time claimed?

Anything else or additional information?

Thank you

 

[trarut]

Visit notes for E/M services should always contain a chief complaint. I would certainly consider coding on time if the documentation contains all of the correct elements to do that -

• total visit time
• percentage of that time spent in counseling or coordination of care
• a description of the conversation and/or care coordination that took place

I also recommend to my docs that they still include some HPI simply to "set the scene" for anyone who may not be familiar with the patient so that the note can stand on its own.

If you don't meet the requirements for time, you can still try to code based on the usual E/M elements. No ROS and no PE means it probably won't go above a level 2, assuming this is an established patient (you don't mention that).

Hope this helps!