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

  1. #1
    Default When time spent counseling is the driving factor for E/M and a procedure is done
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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.
    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

  2. #2
    Sarasota FL
    Default 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.

  3. #3
    Default Thank you
    and he does give details regarding counseling

  4. #4
    Sarasota FL
    Default 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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