AMA CPT® Assistant - 2004 Issue 12 (December)
Evaluation and Management (December 2004)
December 2004 page 19e Coding Consultation:Questions and Answers Evaluation and Management, (Q&A) Question What is the appropriate code to report for a service in which the physician provides only counseling and/or coordination of care regarding symptoms or an established illness to the family without the patient being present? AMA Comment From a CPT coding perspective, time may be considered the key or controlling factor when the physician provides counseling and/or coordination of care that dominates (more than 50%) the patient and/or family encounter. For time to be considered a key component, the physician must spend faceto- face time...
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Article Overview
This brief article presents an AMA CPT coding question and response related to evaluation and management documentation and time-based service selection in an outpatient setting. It is useful for coders, physicians, and billing staff who need to understand the general scope of family-only counseling encounters and how the discussion is framed in CPT Assistant guidance.
Why This Topic Matters
It helps readers recognize the type of evaluation and management scenario being addressed and the general documentation concepts involved, especially when counseling or coordination of care is the dominant service component.
What You Will Learn
- The article’s coding topic and clinical context
- How the guidance frames counseling and coordination of care in a family encounter
- What general E/M documentation concepts are discussed in relation to time-based services
- Which professional audience the Q&A is intended to inform
Who Should Read This
- Professional coders
- Physicians
- Billing staff
- Compliance staff
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