Anesthesia Coding: Unlisted Procedures, E/M and Nerve Blocks
There’s no denying that anesthesia coding is like no other specialty. You have your own codes, rules … and challenges. But dealing with these quirks doesn’t have to leave you pulling your hair out.
E/M Coding: Make the Most of Time with These Tips
Counseling and coordination of care count toward E/M time if done properly
Believe it or not, you have a nifty tool to capture higher-level office visit codes when your pain management specialist or anesthesiologist provides mainly counseling to a patient.
If you overlook CPT’s time rule, you’ll end up with lower-level codes for visits involving mainly counseling and little-to-no history, examination, or medical decision making. Start benefiting from your physician’s time as the controlling factor by checking out these tips.
Tip 1: Verify Note Includes 3 Items
To code based on time in an office setting, your physician must accurately document the following three items:
1: Document that more than 50 percent of the face-to-face time your physician spent with the patient is counseling and/or coordination of care, says Lisa Curtis, CPC-I, CPC-E/M, who specializes in E/M audits in the Greeley, Colo., area. “I advise my providers to state the actual time (for instance, 45 minutes was spent with the patient in total, 30 minutes in counseling).”
An auditor needs to be able to tell the percent of the visit that the physician spent on counseling and/or coordination of care, explains Patricia A. Trites, MPA, CHBC, CPC, EMS, CHCC, CHCO, CHP, CMP, CEO of Healthcare
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