AAPC - Back to school
Results 1 to 4 of 4

Thread: documentation of counseling

  1. #1

    Default documentation of counseling

    AAPC: Back to School
    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
    Join Date
    Apr 2007
    Carmel, 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.


    2016 Secretary
    Ellenville, NY Local Chapter

  3. #3
    Join Date
    Apr 2007
    San Antonio, TX


    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.
    Revenue Cycle Supervisor

  4. #4
    Join Date
    Apr 2007
    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.

Similar Threads

  1. 99354 w/o counseling documentation?
    By PVAzCPC in forum E/M
    Replies: 2
    Last Post: 02-24-2013, 01:49 PM
  2. Replies: 0
    Last Post: 09-06-2012, 10:13 AM
  3. Help! Documentation >50% counseling/cc
    By cadillacmtn in forum E/M
    Replies: 2
    Last Post: 05-02-2012, 07:30 AM
  4. Documentation Smoking Cessation Counseling
    By kwhite2008 in forum Family Practice
    Replies: 2
    Last Post: 04-12-2012, 08:49 AM
  5. Documentation for pediatric counseling
    By jhartung in forum Pediatrics
    Replies: 1
    Last Post: 12-12-2011, 09:33 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.