First, your patient is the mother. (For insurance and billing purposes the child does not exist yet.)
Your documentation should be a "counseling/coordination of care" note, which includes all the following:
1) Total time spent with patient
2) Amount of time spent in counseling/coordination of care (100% of time in this case)
3) Susbstance of the counseling.
For Example: I spent 15 minutes with Mrs Patient, all of which was in counseling regarding the results of MRI of her unborn child.
With this documentation, if the person is a new patient you would code 99201. If a consultation (need to document who requested the consultation), you would codde 99241. If an existing patient, 99213.
Documentation MUST include all three elements to qualify for using time spent in counseling/coordination of care as the basis for chosing the level of care.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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