Wiki New patient

[cruiser1472001]

Provider sees a NP gives 1 bullet in HPI, no pFSH, no ROS, no exam, but spends 50Min with pt. over 50%couseling & coordination of care can I bill a NP visit?

 

[karen57]

If I were auditing this chart, I would have to wonder what kind of counseling and coordination of care the provider could be doing for over 25 minutes for a new patient who he had not examined and from whom he had taken only 1 item of history. Just MHO.

 

[MikeEnos]

According to CMS:

When counseling and/or coordination of care dominates (more than 50 percent of)
the physician/patient and/or family encounter (face-to-face time in the office or other
outpatient setting, floor/unit time in the hospital, or NF), time is considered the key or
controlling factor to qualify for a particular level of E/M services. If the level of service is
reported based on counseling and/or coordination of care, the total length of time of the
encounter should be documented and the record should describe the counseling and/or
activities to coordinate care.

So yes, assuming they have documented the total length of the encounter, that greater than half of it was spent counseling, and the content of the counseling, they can bill the E/M visit based on the time. It doesn't matter what level of history, exam, or medical decision making complexity was documented.