Medicare Compliance & Reimbursement - 2009 Issue 20
READER QUESTION: Count Minutes on 'Counseling Exception' Claims
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Article Overview
This premium article addresses a practical E/M coding question involving a non-physician practitioner, encounter time, counseling or coordination of care documentation, and the relationship between time-based coding and key-component coding. It is relevant for coding professionals, compliance staff, and clinic teams that document outpatient evaluation and management services for new patients, especially when diabetes-related care is discussed. The article also highlights the importance of record support and reviews the general need to select a level of service based on the documented encounter elements when time-based coding is not used.
Why This Topic Matters
It helps coders and clinical documentation teams recognize when time-based E/M selection may be considered, what documentation support is expected, and how to approach coding when the time-based pathway is not appropriate.
What You Will Learn
- How counseling or coordination of care time relates to outpatient E/M selection
- What documentation support is important when time-based coding is considered
- How to think about fallback coding when time-based selection is not used
- How the discussion applies to a new-patient visit involving chronic disease management
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physician practices
- Non-physician practitioners
- Billing staff
Codes Discussed
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