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Category Archives: Medical Coding Exam Prep

Appropriate time documentation?

Hello,

A provider billed 99204 and is using time to meet the level. They document it as below:

40 or more minutes were spent in face to face contact with this patient with more than half of the time devoted to counseling regarding the problems identified

Should credit be given to meet 99204?? How do you know if they truly just spent the 40 minutes or actually spent 45?? Does the total time have to be at least 45 minutes??

The total face to face time for 99204 is 45. The total face to face time is used to make sure more than half of the time counseling and/or coordination of care.

I hope someone can help!