AMA CPT® Assistant - 2007 Issue 1 (January)
Evaluation and Management: Counseling (January 2007)
January 2007 page 28 Coding Communication:Evaluation and Management: Counseling Question I am aware that when counseling and/or coordination of care constitute more than 50% of the physician-patient and/or physician- family encounter, time may be considered the key or controlling factor to qualify for a particular level of evaluation and management (E/M) service. However, I am unclear as to what constitutes counseling. Does the AMA define what constitutes counseling? AMA Comment The CPT nomenclature defines counseling, as it relates to E/M coding, as a discussion with the patient and/or family or other caregiver concerning one or more of the following...
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Article Overview
This article addresses a common coding question about counseling in the context of evaluation and management services. It is aimed at coders, billers, and clinicians who need a clearer understanding of the terminology used in CPT-based E/M reporting and documentation. The discussion focuses on how the term is defined for coding purposes and the broad types of communication it may include.
Why This Topic Matters
Understanding how counseling is framed in E/M coding helps support consistent documentation review and appropriate selection of time-based services when counseling or coordination of care is a major component of the encounter.
What You Will Learn
- How counseling is discussed in the context of evaluation and management coding
- Which broad subject areas may be included in counseling-related discussions
- Why the term matters when time is a key factor in E/M services
- How CPT terminology is used to define counseling for coding purposes
Who Should Read This
- Medical coders
- Billing staff
- Physicians and other clinicians
- Coding auditors
- Compliance professionals
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