Here's my take, and hopefully those who are more qualified to answer will step in. I think this is a case for upcoding the EM based on the documentation elements. In other words 45 minutes would qualify it for a 99215 established patient time based EM assignment based on counseling and coordination of care and the non-face to face Prolonged Service Codes could ALSO be added, but documentation must be concise and detailed. Those prolonged service codes can be a pain to get paid and it's all in the documentation. We're always required to file chart notes and be prepared to appeal . However, the revenue makes it worth pursuing. ---Suzanne E. Byrum CPC
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