Per CPT, when the provider devotes more than 50 percent of his/her face-to-face time with the patient providing counseling or coordinating care, time may be considered the key or controlling factor to qualify for a particular level of E/M service. The documentation should reflect the nature of the counseling or coordination of care the physician provided
Example: A total of 25 minutes were spent face-to-face with the patient during this encounter and over half of that time was spent on counseling and coordination of care.... A brief synopsis of what was discussed (treatment, lifestyle changes, etc) needs to be documented, also.
This would qualify for a 99214.
Curious...what specialty is/are your physician(s)?
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