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Auditing E/M by time

  1. #1
    Default Auditing E/M by time
    Medical Coding Books
    Doctor says "Appointment began at 11:15 and ended at 12:45 for 1.5 hours duration." PLAN: "counseling long time today"

    Would this be enough for code 99215 and 99354?

    Let me know your thoughts!

  2. #2
    Kansas City, MO
    Nope. In order to code based on time the doctor needs to specify that more that 50% on that total time was spent on the counseling, or document the exact time spent ("from 11:45 to 12:45"). A "long time" is not sufficient.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC, AAPC Fellow
    PMCC Licensed Instructor
    2018 Chapter President, Kansas City, MO

  3. #3
    Talking E/m coding on time
    A brief summary of what was discussed also needs to be in the documentation. It doesnt need to be paragraph after paragraph. A simple two to three sentences explaining the nature of the counseling.

    Patti mirolo,cpma,cpc

  4. #4
    Ellenville, New York
    Unhappy Be careful with the prolonged services
    Even with the brief description of the nature of the counseling, there does need to be some detail to support the use of the prolonged service code as well.

    Not looking good for your doc on time-based coding here with these replies!


    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

    2016 Secretary
    Ellenville, NY Local Chapter

  5. #5
    thank you so much!!!

  6. #6
    It would also depend on new or established patient... I believe in your original question you put down the consult code for inpatient (99354)??
    Susan Edwards, CPC, CEDC, AAPC Fellow
    Swainsboro/Statesboro Georgia President

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