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Wiki coding based on time

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LORA CRAWFORD

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If a doctor states in his note that total time of the visit was 1 hour and 45 minutes was spent in counseling could you bill a level 5 for over 50% of the time was in counseling?

thanks for any feedback.
Lora
 
It depends on the level of visit met by the 3 key components. If this were a new patient level 4 then no it could not be up coded as a level 4 says 45 minutes is the assesment time and subtracted from the total time spent leaves only 15 minutes which is not 50% if it is an established patient then yes it is a level 5 or a visit level plus prolonged time. So if this were a 99214 then you would be able to append 99354 as well. There is never an absolute in coding E&M it is all case by case and based on the documentation.
 
I agree it does depend on documentation however:

CPT states, "When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services." This means that time alone can be used to select a level of care, regardless of the extent of the history, exam or the medical decision making, if the majority of the encounter involves counseling or coordination of care. For E/M services, counseling may include a discussion of test results, diagnostic or treatment recommendations, prognosis, risks and benefits of management options, instructions, education, compliance or risk-factor reduction.

Therefore, this encounter was one hour - 45 minutes( over 50%) was spent couseling or coordinating care, therefore, if this was an established patient visit, yes 99215 can be used. Documentation must be very clear on what was discussed.
 
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