Done on the floor/unit
If the meeting w/ family was done on the floor/unit then use the counseling/coordination of care rule to determine the level of E/M.
Documentation must include:
1)Total amount of time spent face-to-face w/ patient (includes unit/floor time in an inpatient setting)
2) Amount of time spent in counseling/coordination of care (must be more than 50% of total time)
3) State nature of the counseling/coordination of care
4) For a patient unable to participate in medical decision making, state WHY patient is unable to participate.
EXAMPLE: After brief examination of patient, I spent time with the family discussing end of life issues and removal of life support. Total time spent face-to-face with patient and family: 45 minutes. Total time spent in counseling and coordination of care: 40 minutes. Patient unable to participate in medical decision making due to comatose state.
If the time spent is sufficiently long, yes, you may be able to code both an E/M and the prolonged service code. Additionally, it is possible that this patient's condition, and the care provided qualify for critical care. It all depends on the documentation.
Hope that was helpful.
F Tessa Bartels, CPC, CEMC