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Documentation for E/M coding based on time..

  1. #1
    Question Documentation for E/M coding based on time..
    Medical Coding Books
    When a provider codes based on time is there a specific way they document this? For example: "I spent 40 minutes with the patient and his brother, and explained all of the changes to the both of them". Is this a valid statement to code a 99215?? Any suggestions on what type of wording that is acceptable would be greatly appreciated!

  2. #2
    My opinion, based on the information given I would have a hard time giving him the 99215. I would need a little bit more documentation as to what was discussed that took 40 mintutes to do so. Was it all face to face with the patient? What was the total time of the visit? In order to bill based on time, the time spent on counseling must be more than 50% of the allotted time for the visit.

    Here is a Website that has helped me alot

    Hope this Helps
    Ivonne, CPMA

  3. #3
    Thank you, that was my instinct too!

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