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Wiki Nature of Counseling

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dtricia

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I have always thought that a provider could summarize the nature of his counseling in his Assessment and Plan. I should be easily inferred. If he then made a time statement of 25 minutes spent in counseling etc I had no problem accepting it, because I could tell what he and the patient had been discussing.
Is this not acceptable? Or does the actual time statement have to stand alone and include the nature of the counseling? I thought 3-4 statements from the provider was in keeping with the intent.
Tricia D
 
I agree with you that if the nature of the counseling is documented in the assessment and/or plan ('counseled patient on diet and healthy food choices') this would be sufficient. Have you been recieving denials or are having a healthy debate in your office on this subject?
 
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