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Reader Question: Patients Treatment Anxiety

Question: How should we charge for patient visits that are extended due to the patients anxiety over treatment? A woman came into our clinic recently for removal of a foreign object in her eye. The service itself was low-level, but it took three times as long to perform due to the patients fear. What is the best way to code this?

Iowa Subscriber

Answer: The time element definitely contributes to the level of service performed, and CPT provides some guidance in this area. It states, When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter (face-to-face time in the office or the 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 service.

In this case, you should judge whether the time spent calming the patient was more than half the total time spent on the case. Then choose the appropriate E/M level for the outpatient visit according to the corresponding time frame: 5, 10, 15, 25 or 40 minutes. Document the time spent in the patients medical record.

Answers to You Be the Coder and Reader Questions were provided by Mark McLeroy, BSRT, administrative specialist, radiology, University Hospital, Augusta, Ga.; Ruthie Burden, CCS, CPC, CPAR, coder for St. Josephs Hospital of Augusta, Ga.; Carol Dodd, RHIT, senior coding consultant with MedQuist of Gibbsboro, N.J.; and John Turner, MD, FACEP, medical director for coding and documentation at TeamHealth Inc., of Knoxville, Tenn.

- Published on 2001-10-01

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