tci Part B Insider - 2010 Issue 6

YOUR PART B QUESTIONS ANSWERED: Code the Highest Level for Counseling

Question: I read your article on coding E/M services based on time from last week's Insider and I have a follow-up question. Our doctor documented 60 minutes on an established patient's office visit. He diagnosed the patient with morbid obesity (278.01) and new onset uncontrolled type II diabetes mellitus (250.02). Since the patient was newly diagnosed and had some difficulty understanding the doctor's orders, the physician spent more than half the office visit time on counseling on therapeutic lifestyle changes and the treatment regimen. Should I code this as 99214 for the first 25 minutes and +99354...

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