A 16-year-old unmarried girl who is eight weeks pregnant scheduled a visit with our physician, accompanied by her mother. There was a lot of crying and discussion regarding options, with much time spent providing emotional support for both women. I would like to record the diagnosis and treatment plan, but not record the history and PMH and ROS because they had little or no bearing on the management. Our physician says I need to document a level-four visit and then code a level-five visit. He told me we may upcode one level based on the time spent counseling the patient. I reviewed the CPT manual where it states that time may be the key component in determining the level of service when 50 percent of the visit deals with counseling and management. I believe this means we dont need to delineate any of the key components. Is this correct?
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Answer: The medical record should always reflect accurately what occurred during the visit. If the physician examined the patient and took a history, these should be recorded. However, it would be appropriate for the practice in this instance to report a level-five evaluation and management (E/M) service based on time. You must make sure the physicians notes clearly indicate the duration of the visit, as well as the issues that comprised the extended counseling session.
Many practices create a stamp for these situations. The stamp may include information like:
Was 50 percent or more of this visit spent on counseling and/or coordination of care?
Total time of visit ______________
Describe content of counseling and/or coordination of care
This type of stamp makes it easier for physicians to document by time when the guidelines are right in front of them.