Cardiology Coding Alert

Cardiologists spend a lot of time with their patients reviewing test results and discussing treatment options, and many are missing reimbursement opportunities by not taking time into account when billing E/M services.
 
If they are not well informed about how time-based E/M coding works, cardiologists may bill visits using 99212 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: a problem focused history, a problem focused examination, or straightforward decision making), when they have really performed a 99213 (... expanded problem focused history, expanded problem focused examination, or medical decision making of low complexity) or 99214 (... detailed history, detailed examination, medical decision making of moderate complexity). Their notes may be in perfect order -- including documentation of the time spent with the patient -- but they continue to base E/M codes on history, examination and medical decision-making, even when the cardiologist performs only a minor examination but spends considerable time with the patient.
 
Physicians may bill for E/M on the basis of time. The introduction to the E/M section of CPT 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 (e.g., foster parents, person acting in locum parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record.
 
 
In other words, if the cardiologist spends more than half the time of the visit going over test results and/or counseling or coordinating the care of the patient, the categories that normally determine levels of E/M services -- history, examination and medical decision-making -- are not taken into account (although they are still performed and should be documented).
 
Cardiology coders are cautioned not to bill E/M routinely using time. "This should not be used for just any office visit. It is not a typical method for choosing the level of service," says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. "Use time only for an exceptional visit -- for example, a visit that includes an extended discussion about things such as prognosis, test results or treatments." She notes that repeated billing of E/M with time as the main factor draws audit attention and limits the number of patients you can see.
 
There are also strict documentation guidelines when billing E/M [...]