Hi there! I am familiar with E/M coding/auditing for Genetic Counseling. Maybe you might suggest to the physician to document time and use the "time component". Per 2008 CPT, pg. 8 - "When counseling/coordinating care dominates more than 50% of the total visit (face-to-face)..time may be considered the key to seleting the level of service..."
The documentation must indicate:
1. the total time
2. the % of time spent counseling
3. what was counseled &/or coordinated
"I spent a total of 80 minutes with this patient and more than 50% was spent on counseling the patient on her paternal lineage" OR
"An extended visit of 75 minutes was conducted for a discussion of the patient's test results, screening and risk-reduction recommendations which all of the time was devoted to counseling"
I hope this helps!!
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