tci General Surgery Coding Alert - 2003 Issue 6

You Be the Coder: Face-to-Face Time During Counseling Sessions

Question: Our surgeon spent time during an office visit counseling a new patient prior to breast biopsy. How should we report this? Tennessee SubscriberAnswer: When counseling is part of a new patient visit, report 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient) depending on the complexity of the patients problem and the time the physician spends with the patient. For instance, if a surgeon sees a new 50-year-old female patient for a stomach ulcer (531.9) and spends 45 minutes face-to-face with her and spends 25 minutes of that 45 minutes counseling...

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