compliant time based coding statement 99215?

kls1027

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Hello,
We are having an inter-office difference of opinion on whether a time based statement for a E5 encounter fulfills the guidelines to charge by time or not, does this statement meet requirements to charge 99215 based on time? The note contains all of the counseling details and the dx to support.
“I spent 40 minutes in counseling and coordination of care with > 50% of that time spent in face to face consultation”

Thanks for your help with this one!

Karen
:cool:
 

Orthocoderpgu

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The time statement alone is not enough for a 99215. The physician also needs to document what the patient was counseled on. This note can be very brief, but the more detail the better. For a 40 minute visit, almost all of that would be counseling time. In my experience, most physicians can complete the ROS and exam in 5 minutes or less. Even a detailed exam. So in reality, you are talking about 35 minutes of counseling. That's a ton of counseling time. Keep in mind MDM. Does the patient's medical condition really warrant 30+ minutes of counseling? I hope this helps with the debate.
 
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As previously mentioned, medical necessity always plays an important role. For example, if a patient presents with a runny nose, ends up with a diagnosis of a cold, and the provider documents "I spent 45 minutes counseling the patient", I would HIGHLY question the reason for the lengthy discussion. The documentation would have to back it up.
 
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