Rounding of time for E/M code selection when couseling & coordination of care dominates the visit

Good afternoon,

If my Ortho DOC see's an established patient and documents:

"I spent 35 minutes face to face with this patient and more than 50% was spent counseling the patient on treatment options were discussed at length as well as the risks and benefits of surgical versus nonsurgical treatment. The patient has failed nonoperative treatment to a reasonable extent, and wishes to proceed with right total knee arthroplasty. The patient understands that this surgery may not resolve all pain or dysfunction. Additional risks of surgery discussed including hardware failure, bleeding, infection, nerve injury, blood vessel injury, blood clots, stiffness, need for further surgery, pain, pneumonia, death. The patient understands and would like to proceed. No guarentees implied or given.

Notable surgical risks include:
None

The patient does NOT have any of the following contraindications to TKA:
Active infection of the affected knee joint, active systemic bacteremia, active skin infection or open wound at surgical site, neuropathic arthritis, rapidly progressive neurological disease, or severe medical condition that makes risks of surgery outweigh the potential benefit.

We have proceeded with preoperative planning, including medical clearance from the primary care provider, participation in the total joint arthroplasty course"

WHAT LEVEL OF E/M WOULD YOU CODE? A 99214 OR A 99215? IS ROUNDING ALLOWED?

Thank you

Penny K. Hanohano, CPC
Physician Liaison
X51455

"I can do all things through Him who strengthens me."`Philippians 4:13
Sign In or Register to comment.