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Ob-Gyn Coding Alert

Reader Question:

Save Time-Based E/M for Counseling/Coordination Heavy Visits

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?Nevada 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, and this fact must be noted in the documentation.How it works: According to this year's CPT® manual, you can use the code closest to the documented time. "If coding by time, pick the closest typical time," said Peter Hollmann, MD, during the "E/M, Vaccines, and Time-Based Codes" session at the CPT® and RBRVS 2011 Annual Symposium in Chicago this past fall.That advice echoes previous AMA information. For instance, the August 2004 CPT® Assistant [...]

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