AMA CPT® Assistant - 1998 Issue 1 (January)
Coding for Counseling (January 1998)
January 1998 page 5 Coding Communication Coding for Counseling The descriptors for the levels of Evaluation and Management (E/M) services recognize seven components, six of which are used in defining the levels of E/M services. They are: history; examination; medical decision making; counseling; coordination of care; nature of presenting problem; and time. The first three components (ie, history, examination, and medical decision making) are considered the key components in selecting a level of E/M services. The next three components (counseling, coordination of care, and the nature of the presenting problem) are considered contributory factors in the majority of encounters...
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Article Overview
This article reviews the role of counseling within evaluation and management documentation and code selection, including how it relates to time-based services and preventive medicine counseling in CPT. It is aimed at coders, billers, and clinical documentation staff who need a broad understanding of when counseling is considered in service selection, how preventive counseling is categorized, and what types of encounters are discussed. The article also distinguishes counseling from psychotherapy and addresses general documentation considerations for reporting.
Why This Topic Matters
Counseling can affect evaluation and management code selection and documentation, especially when it is a dominant part of the encounter. Understanding the article helps readers recognize the general framework used for counseling-related reporting without relying on the premium text.
Article Sections
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Coding Communication
Introduces the article’s focus on counseling within evaluation and management coding and the broader communication context of the topic.
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Defining Counseling
Presents the general scope of counseling as discussed in CPT and the broad categories of communication included in the concept.
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Counseling vs. Psychotherapy
Distinguishes counseling from psychotherapy and describes the article’s high-level comparison of these services.
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E/M Counseling
Covers how counseling and coordination of care relate to evaluation and management service selection and documentation, including time-based considerations.
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Preventive Medicine Counseling
Summarizes preventive medicine counseling and related time-based counseling categories within CPT, along with the types of preventive topics addressed.
What You Will Learn
- How counseling is positioned within evaluation and management services
- How counseling differs from psychotherapy in a coding context
- When time becomes relevant in counseling-dominant encounters
- How preventive medicine counseling is categorized in CPT
- What kinds of encounters are discussed as part of counseling guidance
Who Should Read This
- Medical coders
- Medical billers
- Clinical documentation specialists
- Compliance staff
- Physician practice administrators
Codes Discussed
Code Ranges Discussed
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