Wiki e/m and prolong visits

Local Chapter Officer
Lewiston, ID
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I was hoping someone could help me with a question......
I have been coding e/m for almost 3 years now. I have done several different specialty coding and have started Family practice coding. My question is if you have a provider that is putting on every note "greater than 50% of 60min appt was spent in counseling and or coordination of care." BUT when you read the document you do not have the elements that you need to do a level 5 its more like a level 3 or maybe 4. How or what do you coded off? Do you coded off of the greater than because of the new rule that was made back in 2013 or do you truly go off of the elements and maybe help educate your provider. To let him know if he truly spent X amount of time with pt was it truly in counseling/coordination of care or did he just spend a lot of time so use the prolong visit. Thank you for any help you can give.
Is this possibly a template issue? With EMR I am finding some items get pulled in that really should not be
This is directly off of a CMS MAC Q&A:

When using time as the determining factor for inpatient evaluation and management (E/M) services, does greater than 50% of the time have to be spent in counseling/coordinating care (C/C), or is documenting total time spent on the unit/floor sufficient documentation?

A provider may only use time in choosing the procedure code when spending more than 50% of the total face-to-face time of the visit in counseling / coordination of care. Documentation of the total time of the visit, the time spent in counseling/coordination of care and the nature of the counseling/coordination of care must be in the medical record.

If the medical record does not reflect the required documentation, then use the three key elements of history, exam, and medical decision-making to choose the procedure code.

In the office setting, document the total face-to-face time with the patient. In the inpatient setting, document the total face-to-face time with the patient or on the patient's floor or unit. The face-to-face time refers to time spent with the physician only. Time spent with other staff is not considered in selecting the appropriate level of service.

Thank you for replying but I am coding for Washington state and the link you sent is for other states does that matter? This is for Outpatient. Thank you again and yes I think this is a check on a template but i am being told as long as that sentence is on the note we can code based off of that and that is not what I have experienced in the past. I am just wanting some clarity to it. I don't believe in coding a level 5 unless it is life threatening if provider spent several mins with pt I would rather use the prolong visit. thanks again for all the help. :eek:
Just to add to the discussion, the introduction to the E&M section of the CPT book, under 'definitions of commonly used terms' has a helpful list of topics that fall under the definition of 'counseling'. I agree with the post above that it's not enough just to say that 50% of the time was spent counseling or coordinating care - there's also needs to be documentation of what that time was used for that meets the definitions.
You can also utilize the E/M guidelines (see attached). It states : The record should describe the counseling. If the provider is basing all of their visits on time and utilizing a canned statement he/she could be putting themselves at risk without the documentation describing what the counseling entailed.


  • 97Docguidelines[1].pdf
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  • 95Docguidelines[1].pdf
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