Medicare Compliance & Reimbursement - 2010 Issue 40
Reader Questions: 99214: Take into Account Discussion with Patient
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Article Overview
This reader Q&A discusses when time can be used to support evaluation and management reporting in the outpatient setting and after a patient encounter on an inpatient unit. It is aimed at clinicians and coding professionals who need a clearer understanding of documentation expectations for counseling and coordination-of-care encounters, especially in specialties where discussion-based visits are common. The article also references a specific established-patient office visit code as part of the example guidance.
Why This Topic Matters
Accurate time-based reporting depends on documenting the encounter appropriately and distinguishing time-driven services from component-based selection. This is important for practices that frequently manage complex conditions through discussion, results review, and care coordination.
What You Will Learn
- When time may be used instead of key component-based selection for an encounter
- What documentation elements should support discussion-based visits
- How counseling and coordination of care relate to evaluation and management reporting
- General considerations for outpatient and inpatient time-based visits
Who Should Read This
- Physicians
- Pulmonologists
- Sleep specialists
- Medical coders
- Coding auditors
- Practice managers
Codes Discussed
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