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Thread: Pls suggest code for this scenario?

  1. #1

    Default Pls suggest code for this scenario?

    AAPC: Back to School
    Although we can’t bill for a consent, isn’t it true that we can bill for the time spent with a patient for informing and educating them with regards to the consent?

  2. #2
    Join Date
    Apr 2007


    Are you talking about a visit with the patient, informing them of a surgery or procedure they need and why they need it, then obtaining a consent for it? If so, you probably have documentation to bill an E/M based on time. Make sure total time, counseling time and a synopsis of counseling/visit topic is also documented. The diagnosis would be the symptom/problem that the patient is having the surgery or procedure for.
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I
    AHIMA Approved ICD-10-CM/PCS Trainer
    AAPC National ICD-10-CM Trainer

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default When was decision for surgery made?

    If the decision for surgery was made at a previous visit, then NO, you cannot charge for this service.

    If this is part of the visit at which the decision for surgery is made, you may be able to code the entire visit based on time, if more than 50% was spent on counselling/coordination of care. OR, you spend at least 30 minutes over and above your E/M service, you may be able to use the prolonged service codes.

    Hope that helps,

    F Tessa Bartels, CPC, CEMC

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