This is not prolonged service (which is an add-on code and must be coded the same date of service as the basic E/M)
You can use the counseling/coordination of care rules (mentioned a bijillion times on these forums) to cover this service. Refer to the guidelines in your CPT book.
Your documentation must include:
1) total time spent face-to-face with patinet or family member(s) responsible for medical decision making
2) amount of time spent in counseling/coordination of care (must be >50% of total time)
3) nature of the counseling/coordination of care
4) if patient is unavailable for a medically necessary reason - the reason why the patient could not be present for the visit.
Example: I spent 45 minutes in counseling with Patient's family today. 100% of this visit was counseling, discussing the treatment plan/prognosis and risks/benefits of various treatment options. Patient is unable to participate due to critical nature of his illness and need to limit contact with others for infection control.
45 minutes would qualify for 99215.
F Tessa Bartels, CPC, CEMC
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