tci E/M Coding Alert - 2016 Issue 3

You Be the Coder: Using Time to Choose E/M Level

Question: I have an encounter note in front of me that I cannot decipher. Notes indicate that the physician performed an E/M service for a 67-year-old patient who was just diagnosed with type 2 diabetes mellitus with complications involving the endocrine system. The encounter notes only support a level-two E/M service. However, notes also indicate that the encounter lasted 30 minutes, and 18 minutes of that time were spent discussing treatment options, medication regimens, and potential medication side effects. Can I use the “counseling exception” to code a higher-level E/M in this scenario? Texas Subscriber Answer: As long...

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