This has been addressed in several posts on this and other forums. Search for "counseling/coordination of care." Read the guidelines in CPT carefully regarding counseling/coordination of care (i.e. billing based on time)
You need to document:
1) the total time spent face-to-face with the patient and/or family
2) the amount of the time in 1) that was spent in counseling/coordination of care (must be at over 50% of the total time in 1))
3) The nature of the counseling/coordination of care
AND - if the patient is not able to participate in decision making:
4) WHY the patient is not able to participate in medical decision making.
For example: I spent 25 minutes with Mr & Mrs Patient, discussing Johnny's upcoming surgery, risks, benefits and outcomes were explained in detail. The patient is a pre-verbal infant who is not able to participate in decision making. 100% of the visit was spent in counseling/coordination of care.
You code the dx the patient has that is being discussed. You bill under the patient's name.
NOTE: the reason the patient is not participating has to be medically necessary. Not wanting to pull Johnny away from football practice would not be a medically valid reason for the patient not being present.
The level of service is determined by how much TOTAL time was spent with the "patient and/or family."
Hope that helps.
F Tessa Bartels, CPC, CEMC
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