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

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cwestman

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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
 
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.
 
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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