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Office visit based on time

  1. #1
    Peoria Illinois Chapter
    Default Office visit based on time
    Medical Coding Books
    I would like clarification on what needs to be documented in the note to qualify for an office visit based on time.
    The CPT guidelines state that when counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family, then time shall be considered the key or controlling factor to qualify for a particular level of E/M service. It also states the extent of counseling and/or coordination of care must be documented in the medical record.

    I have an established patient with breast cancer, on chemotherapy, that is being seen to go over results of testing and to established a future plan for treatment. This patient's note is entirely based on counseling and coordination of care, and the documentation includes information regarding the discussion and a plan for treatment.
    Since this visit doesn?t have a typical History/Exam/MDM, what would you have to have to qualify other than the amount of time spent?

    Can you tell me if any of the below examples qualify or not?
    1. A total of 15 minutes was spent with the patient.
    2. A total of 15 minutes was spent with the patient going over results of recent testing and options available.
    3. I spent 15 minutes with the patient counseling her on the recent testing results and options. Greater than 50% of this visit was spent in counseling and coordination of care.

  2. Default
    #3 would be best. A typical example my practice uses would be something like "20 of 30 total minutes was spent counseling patient about..." You would state how much time was spent counseling out of the total time spent with the patient and why.

  3. #3
    ST Paul, MN
    I agree with cldavenport that #3 would be the best option. As a payer, when we see notes supporting E/M codes with time, they are usually written as '25 minutes spent with the patient, >50% of this was in counseling' or some variation of that.
    Brian Johnsen, CPC
    St Paul, MN

  4. #4
    Default #3
    Number 3 definately without a doubt! CPT specifies that it must be documented within the chart note and that it is >50% of the time spent in face-to-face coordination of care and counseling.

  5. Default
    yes sure, and always we need to keep in our mind on this time based E&M levels must have TTS(total time spent) and the CTS(counseling time Spent) which must be >50% of the total time spent
    Beula Selvan. B.P.T.,CPC.,

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