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time reguardless of counseling

  1. #1
    Default time reguardless of counseling
    Medical Coding Books
    what's the rule about coding based on time. I understand about counseling, it has to be at least 50%of total time spent with patient...but here's the question; can't we code based on time alone? if they state I spent 45 minutes with the patient, can we code based on the time spent, without mention of counseling?

    thanks for any help!

  2. #2
    Smile CPT Assistant Issue August 04
    Hi. You cannot use time alone. These are the requirements per the above CPT Assistant. 1) The physician must include a record of total time of the visit as well as the time spent in the specific counseling or coordination of care. 2)The note should include a summary of the content of the counseling that occured.

    If counseling and/or coordination of care did dominate the visit, then the code is selected based on the total time of the visit.

    You can also find these guidelines in the CPT book Evaluation & Management Guidelines.


    Christy RHIT, CPC

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