How to code patient education
If more than half of a new or an established patient visit is spent on counseling, bill an evaluation and management code, and choose a code on the basis of time spent, face-to-face.
Examples of counseling include giving diagnostic results, impressions and/or recommended diagnostic studies; discussing prognosis; discussing risk and benefits of treatment options; giving instructions for treatment and/or follow-up; discussing the importance of compliance with chosen treatment options; discussing how to reduce risk factors; and educating patients and families.
That is, if the visit is 40 minutes, and 21 minutes are spent on counseling an established patient, bill a 99215.
Check the Current Procedural Code (CPT) manual for the times which correspond with the evaluation and management codes for office or hospital visits.
Be sure to document the length of time of the encounter and/or the time spent in counseling.