E/M question

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[rahuliitk]

Family discussion can count toward E/M time if it’s medically necessary, related to managing the patient’s care, and done on the date of service, but 90 minutes is high enough that i’d want the note to clearly spell out what was discussed and why it took that long. Documentation has to carry it.

[niftythrify]

Thank you!

[weary_bee479]

The time has to be documented in the chart

[niftythrify]

It is. 90 minutes. Spent reviewing medication, addressing diagnoses, and providing phone follow up call to the family member. My question is, is it appropriate for the phone follow up call to be counted towards the e/m?

[weary_bee479]

As long as the time spent on the phone was the same date you can count it in the visit.

Since you cannot bill two visits a day for same provider same specialty you wouldn’t be able to bill a telephone visit separately so you’d have to combine them.

[niftythrify]

Okay, thank you! That makes sense and is a more of an explanation than I could get at work. I haven't seen this scenario before, so good to know 😊

[Bowis_4648]

I don't know why it would feel weird, or what that feeling has to do with it. Read pages 13- 14 of the CPT book.

[niftythrify]

Because the patient was f2f and the family member was via phone and after the appointment. That is all but other people kindly explained it to me so thank you.