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E & M Code

  1. Default E & M Code
    Medical Coding Books
    I have an office note for an established pt that meets every component for a level 5 visit but at the end of all of the documentation the provider mentions that he spent 30 minutes with the patient. A level 5 has a 40 minute time mentioned in the CPT book. Does this mean that the level should drop to level 4 even though he is not using time as one of the components for choosing a level? Thanks for the help!

  2. #2
    Default
    You can either code by scoresheet OR by time, whichever is more beneficial to the provider. However, there are rules to abide when coding by time. Documentation must state the total time spent with the patient, that over half the visit was spent on counseling or coordination of care, and must describe the content of the counseling or coordination of care.

  3. #3
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    Quote Originally Posted by turnerdc@gmail.com View Post
    I have an office note for an established pt that meets every component for a level 5 visit but at the end of all of the documentation the provider mentions that he spent 30 minutes with the patient. A level 5 has a 40 minute time mentioned in the CPT book. Does this mean that the level should drop to level 4 even though he is not using time as one of the components for choosing a level? Thanks for the help!
    The time listed with the E/M codes are suggested times not actual times that must be spent with the patient. Those times only come into play when you are coding based on time alone...as long as all the key elements for a level five visit have been documented then you are safe to use the level five code.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

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