Your documentation states:
"We again spent 30 to 40 minutes ..."
First, "30 to 40 minutes" does not tell me that it was definitely over 30 minutes. Sounds like the physician is guessing as how long a time was spent. Could be only 30 minutes, which would be 99238.
On the other hand, s/he also writes "again spent" ... which might mean that there was a different session with the patient going over these issues, over and above the basic service, which would tend to make me think the total work involved was truly over 30 minutes. But I don't know this physician, so am not familiar with the usual way s/he dictates.
I'd educate the physician on the time requirements for this code so s/he could be more clear in the future.
To answer your basic question, I'd code this 99238 unless the physician could clearly demonstrate that the time spent was over 30 minutes.
F Tessa Bartels, CPC, CPC-E/M
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