Coding: Your Top Coding Concerns Solved
Using time to code for office visits; Who, what, when, where, and why?
By Betsy Nicoletti If you’ve ever read a patient the Riot Act, use time to document that visit.
Most physicians know they can use time to select a code for an office visit or consult, but many forget when, why, and how to do it.
According to the CPT book and documentation guidelines, if you spend more than half the visit discussing the patient’s illness and treatment, use time to select the code rather than the level of the history, exam, and medical decision-making you perform.
Here are some examples:
An endocrinologist sees a diabetic patient. After a brief history and exam, they talk about diet, blood sugar monitoring, the importance of tight control, and medication adjustments.
An oncologist sees a patient for follow-up, and the patient’s cancer has not responded to the first course of treatment. The entire visit is spent discussing other treatment options.
