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When time spent counseling is the driving factor for E/M and a procedure is done

cwestman

Networker
Messages
69
Best answers
0
I'm hoping someone can advise me on this dilemma
I have a provider who will use time spent counseling as the driving factor for E/M.
Example
Pt her for f/u DM,HTN,Hyperlipidemia etc, ROS HPI PFSH and Exam are comprehensive to detailed ,med changes made counseled on diet ....
However sometimes the patient will request a joint injection or lesion removal during the appt and the procedure is done during the visit
he documents 30 minute appointment with >than 50% face to face etc-99214
adding 20610-50 for bilateral knee injections
Am I wrong in thinking that in that 30 minutes the knees were injected as well ?
I'd like to address this with him ,however I know that this will not be received well so I'm hoping someone can confirm or not whether I'm right or wrong
and if there is any information I can use to support changing
Thany you in advance
Cheri
 

twizzle

True Blue
Messages
1,127
Location
Sarasota FL
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0
Time spent counseling

If your provider documents 30 minutes spent with >50% counseling, but does not document the time spent on the procedure then the encounter cannot be coded on time. He needs to say '30 minutes spent with >50% counseling, exclusive of time spent performing the procedure' or words to that effect.

All this assumes of course that he documents the nature of counseling for any encounter where he dictates a time statement. The statement alone is insufficient.

Hope this answers your question.
 

twizzle

True Blue
Messages
1,127
Location
Sarasota FL
Best answers
0
Time spent counseling

Well, at least the nature of counseling is documented but my comments still stand...... if they are doing a procedure as well as an E/M, the time spent on the procedure cannot be included in the total visit time; performing a procedure is not counseling.

For a 30 minute visit you cannot code on time because you don't know how long the procedure took unless he tells you. You need to discuss this with the provider.
 
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