Read your CPT Guidelines on Counseling/Coordination of care.
Physician must document ALL three of the following
1) TOTAL face-to-face time spent with patient
2) Amount of face-to-face time spent in counseling/coordination of care (must be at least 51% of total time)
3) Summary of the counseling/coordination of care.
For example: I spent 38 minutes with Mrs Patient today, discussing her prognosis, paliative measures and expected course of her disease process. All questions were answered and she expressed understanding. 100% of visit was spent in counseling/coordination of care.
Then you will choose the level of E/M based on the TOTAL time spent.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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