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Wiki Time Based Coding

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chrissylyman0629@gmail.com

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