tci Part B Insider - 2011 Issue 38

Reader Question: Know CMS Vs. CPT® Differences When Counting Time

Question: If the physician documents: "Time spent in the evaluation of the patient with mostly medical decision making time (two thirds) is 75 min" can I choose the E/M code based on time alone?Answer: No, you cannot code based on time with just the documentation you have mentioned. Here's why: You should only code an E/M service based on time alone if at least 50 percent of the visit was spent on counseling or coordination of care. How it works: According to the 2011 CPT® manual, you can use the code closest to the documented time if coding...

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