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documentation of counseling

  1. Default documentation of counseling
    Exam Training Packages
    When the provider says greater than 50% of the visit was spent counseling the patient on tobacco cessation and the visit was 15 minutes, what is recommended for documenting the visit content? My providers are just giving the topic but no details of what was actually said. We feel that there should be more details to show what was discussed. If the chart was audited, what does the auditor expect to see?

  2. #2
    Ellenville, New York
    Default Some detail is needed
    There should be some level of detail. Was the smoking cessation counseling about options (i.e. patches, gum, cold turkey) or dangers of smoking? Something like that is what I would search for.


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

    2016 Secretary
    Ellenville, NY Local Chapter

  3. #3
    I look for some indication of what was discussed, such as the options for stopping smoking, health hazards or other information. Just saying he counsled the patient is not enough.

  4. #4
    Tyler, Texas
    Is the provider billing for smoking cessation counseling OR an E&M service based on time? If the former, then this is probably sufficient for the Medicare smoking cessation counseling code. However, if billing for an E&M, the specifics of the counseling should be documented. In auditing, I usually give credit for any specifics beyond "I spent > 50% of the f2f time of 15 minutes in counseling and coordination of care". That statement alone does not cut the mustard for me. For time based E&M, providers should give 3-4 precise statements as to what the session entailed.

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