You state the patient was "severelly mentally handicapped and frightened."
I can only assume that there was a family member or other caregiver - someone responsible for medical decision making - along with the patient on this visit.
Here is where your physician should have documented time spent face-to-face with patient and family member, discussing condition and plan of treatment.
You would need: TOTAL face-to-face time spent with patient; amount of that time (must be > 50%) spent in counseling/coordination of care; a summary of the counseling/coordination of care.
Then the visit could be coded based entirely on time.
10 minutes = 99201
20 minutes = 99202
30 minutes = 99203
45 minutes = 99204
60 minutes = 99205
Hope that helps.
F Tessa Bartels, CPC, CEMC
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