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Counseling session with mom-how to code

  1. #1
    Default Counseling session with mom-how to code
    Medical Coding Books
    My doctor seen a mom for 30 minutes to discuss her child behavior problems (11yrs old). The child was not in the office with the mom. My doctor referred the mom to an psychiatrist for a psy eval.

    How do I code this?


  2. #2
    Default counseling
    If counseling took place for 50% of the visit time, you may code for an office visit. Select an office visit whose associated time matches the total time of the visit.

    Page 40 starts explaination of how to code for time based counseling. Note that even when coding based on time, you STILL must meet the threshold of medical necessity for the counseling.

    hope this helps this site may also be useful
    Last edited by jackson7591; 07-28-2011 at 12:49 PM.

  3. #3
    So I would code an Establish Office Visit? Even though my doctor did not see the patient (child) on this particular day, the mom came in to discuss her child behavior problems?

  4. #4
    Default reference

    Yes. So long as the person being counseled is responsible for the child and makes decisions on the child's behalf. Bottom of page one of this site. But again, need to establish a medical necessity for the visit.

    Also need documentation to establish relationship between the patient and the individual being counseled. Simply stating "mother of patient" is a good start, but more documentation is always better. "mother of patient who is currently responsible and involved in patient's care." would be even clearer. I'm always reminding our provideres to explain clearly their thought process.

    anyone else?

  5. #5
    Thanks for your help and reference material.

  6. #6
    Default no problem
    happy to help/provide information. I always either learn new information and references or better my understanding.

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