tci Outpatient Facility Coding Alert - 2016 Issue 3

Coding Notes: Time Alone Is Sufficient to Select a Counseling Level of Care

Watching the clock can make all the difference. Many factors go into selecting an E/M code, but CPT® considers time to be the key to determining the appropriate code for provider/patient counseling. Here’s your refresher on how to arrive at the correct code for these situations. Remember What’s Included When you code based on time for professional fee services in the outpatient setting, you can count only the face-to-face time with the patient or family. This time calculation includes the time spent counseling as well as the time associated with any history, exam, or medical decision making...

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