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counseling dx

  1. #1
    Default counseling dx
    Medical Coding Books
    How would you code out the below scenario:

    An established patient's son comes in to discuss "end of life-hospice" with our cardiologist. The doctor spent 30 min w/ son to discuss options. The son is not a patient, but the visit was with him and the dad was NOT present. I feel that I would code out a counseling code- set the son up as a patient and use a cardiology counseling dx.

    Does this sound like I am on the right track?? Has anyone coded out a visit like this before?
    please help!!!!!!!!!!!!!!!!!

    thank you ,


  2. Default
    You did say when the father was last seen or if there is an upcoming visit but have you considered 99358 with the father remaining as the patient. You would have to have a minimum of 30 minutes of documented time in order to code the 99358

    99358 Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (e.g., review of extensive records and tests, communication with other professionals and/or the patient/family); first hour

    99359 each additional 30 minutes

    Evaluation and Management (E/M): Prolonged Physician Service Without Direct (Face-To-Face) Patient Contact

    Guidelines have been revised to clarify that prolonged services without direct (face-to-face) patient contact codes are to be reported for prolonged services that are beyond the usual non-face-to-face component of the physician service time. Also, the add-on status has been removed from code 99358, which helps clarify that the prolonged services (99358 and 99359) may now be reported on a different date than the primary service to which it is related.

    However, the guidelines specify that the prolonged service must relate to a service or patient where direct face-to-face patient care has occurred or will occur and relate to ongoing patient management. The primary service to which the prolonged service is related does not need to have a typical time established in the CPT code set. Additional language states that 99358 should be used only once per date.

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