Counselling & Coordination of Care
CPT states that when more than 50% of the time spent in face-to-face visit is for counselling & coordination of care, then TIME SPENT determines the level of the E&M visit. (see page 8 of the 2008 CPT Professional Edition, paragraph 3.)
The physician must document:
TOTAL time spent face-to-face
Amount of time spent in counselling/coordination of care
General description of reason for counselling.
As an example:
I spent 40 minutes with Patient today, 100% of time in counselling & coordination of care, discussing end-of-life issues and assisting patient with preparation of living will, DNR documents.
If this was a new patient, this above "note" would be coded as 99203.
If it was an established patient, it would be coded as 99205.
F Tessa Bartels, CPC EMA