Wiki too much time spent deciding to perform procedure

[JesseL]

So the story I'm given is patient has a wart.

This usually is billed with 17110.

Before the procedure, patient called her husband because she can't make her own decisions.

Her sister was also in room asking a million questions and driving the doctor insane regarding this treatment.

Total time spent with patient before the procedure was 2 hours because of patient indecisiveness.

Would you code a time based E&M on top of the 17110?

 

[mitchellde]

yes you can use prolonged time if well documented and all face to face with provider. however without more diagnosis to indicate the nature of the prolonged time you will have a hard time with reimbursement. Look in categories R40-R46 to see if the provider documented any of those symptoms in addition to the wart. You may also look at the Z71 category due to the sister's involvement. The point is you must communicate with codes the reason for this additional time for something as simple as a wart.