Time help

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This is what was said:

I have discussed the findings at great length with the patient, his wife and 3 daughters. I have had an extensive perhaps 40 minute discussion at great length with the family about the current situation and likelihood of metastatic prostate cancer. And then goes on about what they have discussed for about a paragraph.

The patient had a cystoscopy done before this for gross hematuria.
 

trarut

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Okay :) All information is based on this being performed in a physician office where only face-to-face time counts.

Does this qualify? I would code this based on time. You have time spent with the patient, content of the discussion and I would consider "at great length" to be the majority of the visit time.

What visit level? It depends on the type of visit. For a 40 minute time-based visit, it would be a 99204 (new patient), 99243 (office consult) or 99215 (established patient visit).

Hope this helps!
Tracy
 
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