Time based coding

umas86

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Hi,
I have a doubt regarding time based coding of E/M. This is a consultation report and it states " Total visit of patient is 50 minutes and more than 50% time was spent on counseling and coordination of patient".Please clarify should i code it as 99243 or 99244.
 

btadlock1

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Hi,
I have a doubt regarding time based coding of E/M. This is a consultation report and it states " Total visit of patient is 50 minutes and more than 50% time was spent on counseling and coordination of patient".Please clarify should i code it as 99243 or 99244.
Documentation guidelines state:
"In the case where counseling and/or coordination of care dominates (more than 50%) of
the physician/patient and/or family encounter (face-to-face time in the office or other or
outpatient setting, floor/unit time in the hospital or nursing facility), time is considered the
key or controlling factor to qualify for a particular level of E/M services.

DG: If the physician elects to report the level of service based on counseling
and/or coordination of care, the total length of time of the encounter
(face-to-face or floor time, as appropriate) should be documented and the
record should describe the counseling and/or activities to coordinate care."

The provider can't just say that he had a talk with them for the length of time, without documenting what he counseled them on, or what else he did to justify spending the amount of time that was spent on the visit. The service still has to be medically necessary; he can't just take an extra long time with patients for no reason. Although I'm sure there was a good reason, without documenting it, for all anyone knows, they spent 45 minutes discussing the weather.

That said, if he did document his efforts properly, then you should go with whichever level is best supported by medical necessity - check Appendix C in the back of your CPT book for examples. If what you shared above, is all that's documented about the counseling/coordination of care, then I wouldn't consider it to have been documented properly, to assign a code based on time. Hope that helps! ;)
 
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