Correctly Code Patient Counseling

Use sign, symptom, or condition to prevent confusion
with Preventive Medicine Counseling codes (99401-99404).

By William P. Galvin, CPC

A patient’s status—new, established, or consultation—isn’t the only element you should consider when coding an evaluation and management (E/M) office or other outpatient service. You also need to match the usual time associated with the E/M codes with the documented time spent counseling the patient for her sign, symptom, or condition.

The usual time associated with E/M office or other outpatient clinic visit codes are shown in Table A.

Table A. When choosing an E/M code, consider the time element in addition to the patient’s status.

New Patients             Established Patients    Consultations

99201–10 minutes         99211–5 minutes          99241–15 minutes

99202–20 minutes         99212–10 minutes        99242–30 minutes

99203–30 minutes         99213–15 minutes        99243–40 minutes

99204–45 minutes         99214–25 minutes        99244–60 minutes

99205–60 minutes         99215–40 minutes        99245–80 minutes

CPT® 2009 states, “When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (eg, foster parents, person acting in loco parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record.”

For example, Monday, an established patient with diabetes Type 2 (ICD-9-CM: 250.00 Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled) presents for a follow-up visit. The provider performs and documents a detailed history, detailed exam and moderate medical decision-making (MDM).

Using history, exam, and MDM as the key components, the CPT® code selection should be 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

As part of the MDM, the provider instructs the patient to go to the lab for an A1C, CPT® 83036 Hemoglobin; glycosylated (A1C) blood (except reagent strip). The patient complies and goes to the lab on Wednesday for the blood work. When the results come back, the provider reviews the results and schedules a face-to-face visit with the patient to discuss the results and to set a course of action for treating the patient’s medical condition.

Note: Lab results and counseling via phone does not constitute the use of telephone E/M codes because the phone call is the result of a sign, symptom, or condition addressed within the last seven days of an E/M visit.

Friday, the established patient returns. Because the patient was just seen Monday, only a problem focused history, problem focused exam, and moderate MDM are performed and documented. In the progress note’s documentation, the provider states, “Spent approximately 25 minutes, of which 50 percent of the time was spent counseling (describe the counseling or coordination of care) the patient on the risks of diabetes, how to eat healthy, the use of home glucose testing, how to begin or expand on a exercise regiment, and prescription drug management if needed, etc.”

Using history, exam and MDM as the key components for this E/M visit, the CPT® code selection should be 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.

If you use time (25 minutes) as the key controlling factor for this E/M visit, however, your code selection could be 99214 for this visit as well.

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