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Thread: Physical with a E&M based on time?

  1. #1

    Default Physical with a E&M based on time?

    AAPC: Back to School
    I have some pediatric physicians who do regular physicals but also send a great deal of time consulting about ADHA and other behavioral health disorders. These are hard to document without using a time statement. Can a time statement be used with a physical if is specifically states that time is over and above the time spent doing the physical?

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    If you are referring to the preventive levels, these cannot be upcoded or have prolonged time appended.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3


    I was referring to adding an E&M with a modifier 25 but instead of meeting the HPI, exam and MDM requirements using time instead since it is a mental health issue and hard to document.

    Dana CPC

  4. #4
    Join Date
    Apr 2007
    Milwaukee WI

    Default Problem focused established patient

    So what you would be coding would be a problem-focused established patient exam, based on time spent in counseling/coordination of care.

    For example: I spent 15 minutes with Johnny & his mother discussing Johnny's ADHD, medication options, behavior modification, and issues with schooling. 100% of this problem focused visit was spent in counseling/coordination of care.

    Ideally this would be documented as a separate note, not just buried in the report of the preventive exam.

    You would then code 99213-25 for this portion of the total visit.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. #5


    Thank you for your reply.


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