tci General Surgery Coding Alert - 2004 Issue 6

How to Choose Between Time-Based E/M, Prolonged Service

Start with history, exam and MDM Your general surgeon conducts a 50-minute established outpatient visit during which he spends 35 minutes on coordination and care. Should you report 99215, or 99213 with +99354 (Prolonged physician service in the office or other outpatient setting ...)?CPT specifies that if counseling and coordination of care consume 50 percent or more of an E/M visit, you may use time as the determining factor when selecting an appropriate E/M level. How, then, do physicians and coders decide when to report prolonged services and when to use time to justify a higher E/M level...

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