How to Document E/M with Counseling and Coordinating Care

How to Document E/M with Counseling and Coordinating Care

The only case when time may be used as the overriding factor in determining an evaluation and management (E/M) level is when counseling and/or coordinating care dominates the encounter, which means that the time expended on counseling and/or coordinating care exceeds 50 percent of the total encounter time. This applies to non-time-controlled E/M services that have reference times assigned to them by the AMA in the CPT® code book. This means that the counseling/coordinating care time rule applies to:
99201-99215 Outpatient new and established patient visits

  • 99241-99245 Outpatient consultations
  • 99221-99233 Inpatient new and subsequent visits
  • 99251-99255 Inpatient consultations
  • 99218-99220 Observation -initial visit (Outpatient)
  • 99224-99226 Observation – subsequent (Outpatient)
  • 99234-99236 Observation admit & discharge – same calendar day (Outpatient)
  • 99304-99310 Nursing Facility Care (Inpatient)

This rule does not apply to Emergency Department Visits, 99281-99285 and preventative care visits, 99381-99396 because there are no reference times assigned by the AMA in CPT®. It also does not apply to time-based codes for critical care, 99291-99292.

Three Key E/M Items

Three key items must be documented when relying on counseling and/or coordinating care dominating the encounter to determine the level of the encounter. Those three items are:

  1. Total time of the encounter
  2. Time spent counseling and/or coordinating care which represents at least more than 50 perfect of the encounter
  3. What topics were covered in the counseling and/or what areas of care were coordinated during that time. This can be a bulletted list.

As an example, subsequent outpatient visits have AMA assigned reference times assigned to the codes as follows:

  • 99212 10 minutes
  • 99213 15 minutes
  • 99214 25 minutes
  • 99215 40 minutes

If a physician has a surgical discussion with a patient after a biopsy comes back malignant the documentation may reflect:
Total time of encounter: 30 minutes
Twenty minutes were spent counseling patient face to face about options based on biopsy results.

  • Biopsy results
  • Surgical options
  • Success expectations
  • Post-surgical expectations
  • Post-surgical treatment options for Chemo and Radiation
  • All the patient’s questions were answered

This encounter can be coded as a 99214 even though there may not be a documented history, exam, and MDM because the documentation meets the requirements for counseling representing over 50 percent of the visit.
When a patient is an inpatient status (hospital inpatient or nursing home inpatient), the time is counted as floor time, not just face to face time. This can include time spent counseling with the family and coordinating care on the floor.
The AMA CPT® reference times for subsequent hospital visits are as follows:

  • 99231 15 minutes
  • 99232 25 minutes
  • 99233 35 minutes

Remember that patients in observation have an outpatient status. That means that floor time cannot be used and only face to face time with the patient can only be used for patients in observation.

Evaluation and Management – CEMC

Barbara Cobuzzi

About Has 99 Posts

Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, is an independent consultant, CRN Healthcare Solution, Tinton Falls, N.J. She is consulting editor for Otolaryngology Coding Alert and has spoken, taught, and consulted widely on coding, reimbursement, compliance, and healthcare-related topics nationally. Barbara also provides litigation support as an expert witness for providers and payers. Cobuzzi is a member of the Monmouth, N.J., AAPC local chapter.

5 Responses to “How to Document E/M with Counseling and Coordinating Care”

  1. Jennifer Strang says:

    Thanks for this post. I had a discussion with a Thoracic surgeon yesterday and we discussed billing based on time. Would he be able to utilize the time he spends reviewing all patient imaging as time counted toward coordinating care in the outpatient office setting in order to meet a LOS?

  2. Barbara Cobuzzi says:

    Only if the time reviewing the imaging included face to face with the patient – reviewing the imaging with the patient in front of you, then you can count the time. Time in the outpatient setting is only patient face to face time. But time in an inpatient setting counts floor time which is not face to face patient time, so time reviewing imaging on the floor in an inpatient setting would count

  3. Shelly says:

    I work in an Oncology Department and our NP see’s the patient for Chemo Teaching. We charge with the 99212-99214. I was wondering if I should code the principal diagnosis as Z71.89 (Medication counseling, other specified counseling).

  4. Barbara J. Cobuzzi says:

    I think that the Z code would be used as the primary diagnosis as that is the reason for the encounter. The patient’s cancer should also be coded since the patient would not have to receive this counseling if they did not have the cancer. I would also code Z51.11, Encounter for antineoplastic chemotherapy, if the patient receives chemotherapy during the encounter.

  5. MJ Sanford says:

    Our provider is also providing counseling for several patients with regards to pain management. Our notes specify the amount of time he is spending face to face with the patient. For example he may state that he spent 25 minutes face to face with the patient, greater than 50% was spent counseling the patient on……… He then describes the counseling he gave in the encounter note. I have been told this is a sufficient time statement. I was wondering if I needed to add anything else to this statement.