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General Surgery Coding Alert

Reader Question:
Count Time Differently for CPT® vs. CMS

Question: If the physician documents: "Time spent in the evaluation of the patient with mostly medical decision making time (two thirds) is 75 min," can I choose the E/M code based on time alone?Texas SubscriberAnswer: No, you cannot code based on time with just the documentation you have mentioned. Here's why: You should only code an E/M service based on time alone if at least 50 percent of the visit was spent on counseling or coordination of care. How it works: According to the 2011 CPT® manual, you can select the code that represents the time "closest to the documented time." That advice echoes previous AMA information. For instance, the August 2004 CPT® Assistant states, "In selecting time, the physician must have spent a time closest to the code selected."For example: For a 35-minute visit spent on a medically necessary counseling-dominated visit, per CPT® you could report 99215 (Office or [...]


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