Wiki Time Based Coding

[chrissylyman0629@gmail.com]

Are counseling topics required to be documented when billing for counseling time of greater than 50% of encounter?

 

[missy874]

Yes, per CPT "the extent of the counseling and/or coordination of care must be documented in the medical record." This is interpreted to mean the details of what you counseled on or how you coordinated care. When I inform my providers of this requirement, I generally let them know that its important not only for billing but for continuity of care.