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Thread: E&M coding based on time

  1. #1

    Question E&M coding based on time

    AAPC: Back to School
    We recently had a debate with my Doc regarding time based coding. Doctor saying that since some insurances do not cover smoking cessation consulting and counseling is actually done we need to code it as time based E&M visit. I personally think that since CPT code for tobacco counseling exist it should be separated from E&M. Also I’m not sure if we can bill insurances differently depending on benefits. Any suggestions?

    IV. Documentation of an Encounter Dominated by Counseling and/or Coordination of Care
    When counseling and/or coordination of care dominates (more than 50 percent of) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting, floor/unit time in the hospital, or Nursing Facility), time is considered the key or controlling factor to qualify for a particular level of E/M services. If the level of service is reported based on counseling and/or coordination of care, the total length of time of the encounter should be documented and the record should describe the counseling and/or activities to coordinate care. For example, if 25 minutes was spent face-to-face with an established patient in the office and more than half of that time was spent counseling the patient or coordinating his or her care, CPT code 99214 should be selected.
    Oksana Pokoyeva, CPC
    WCH Service Bureau
    Email: oksanap@wchsb.com

  2. #2
    Join Date
    Apr 2007
    Rose City (Portland, Oregon)


    You absolutely cannot bill a different code because the one that fits the situation will not be paid. You must use the most accurate code that describes the service provided.

  3. #3


    Thank you for your response. But do you know where i can find something in writing about this?
    Thanks again

    Oxana Pokoyeva, CPC
    Last edited by oksanap; 07-08-2010 at 11:55 AM. Reason: typo

  4. #4
    Join Date
    Apr 2007
    North Carolina


    CPT Professional Edition 2010-(beginning pages)

    Instructions for use of the CPT Codebook

    "Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided."

    To select another CPT code to simply get it paid is a false claim. If audited, the carrier will recoup the payment and potentially impose fines.

  5. #5
    Join Date
    Apr 2007
    Dover Seacoast New Hampshire


    There's nothing that I know of that specifically addresses this issue specifically in regard to the smoking cessation codes other than that andersee is correct in that you must code to the nearest specificity for all services provided. The CMS fraud and abuse guidelines address issues regarding billing and coding appropriately. Here's the link from the Federal Register regarding physician practice compliance.

    Pam Brooks, MHA, CPC, PCS, COC
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

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