Question: How should I bill for face-to-face Counseling time spent with the patient?

Answer: A provider may only use time in choosing the procedure code when spending more than 50% of the total face-to-face time of the visit in counseling / coordination of care. Documentation of the total time of the visit, the time spent in counseling/coordination of care, and the nature of the counseling/coordination of care must be in the medical record.

Counseling is a discussion with a patient and/or family concerning one or more of the following areas:

  • Diagnostic results, impressions, and/or recommended diagnostic studies,
  • Prognosis, Risks, benefits of management (treatment) options,
  • Instructions for management (treatment) and/or follow-up
  • Importance of compliance with chosen management (treatment) options,
  • Risk factor reduction, and
  • Patient and family education.

ChiroCode has a sample form to use for E/M Counseling. See the DeskBook Resources page. Remember when billing for counseling on the same day as the CMT-98940-98942 services you must add modifier 25 to the E/M code and attach the Counseling documentation that shows your face-to-face time and the components discussed.