E/M Weekly Tip: Counseling/Coordination Office Setting

Office or Other Outpatient Setting
Counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided.

Patient Is Not Present in the Office
Counseling/coordination of care with the patient’s family alone (i.e., patient is at home) is not a billable service.

Patient Is Present in the Office
If the family members/provider needs to perform counseling/coordination of care away from the patient they may leave the room and go to the hallway or private room. Time with the family may be included in the selection of the CPT code.

Resource
For more information, please visit the Medicare Claims Processing Manual, 100-04, Chapter 12, Section 30.6.1 C at CMS website (PDF).