Yes, you can use time spent in counseling/coordination of care in the inpatient setting to determine level of service.
The note must state:
1.Total amount of time spent face-to-face with patient (floor/unit time counts for inpatient)
2. Amount of time spent in counseling/coordination of care (must be at more than half the total time)
3. Nature of the counseling/coordination of care.
So, for example, you might have documentation such as: I spent 30 minutes with patient and his parents, 18 minutes of which was in counseling/coordination of care, discussing diagnosis, treatment options, risk and benefits.
NOTE: 30 minutes in an inpatient setting equals a 99232 subsequent hospital visit. If the patient is sufficiently ill, the physician may have already documented a 99233 visit level. For a subsequent visit you only need to meet the standard on two of the three: history, exam, MDM.
F Tessa Bartels, CPC, CEMC
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join