Just because the physician spends more than 50 percent of the visit counseling doesnt mean the visit is going to last longer than usual. You could have a visit with more than 50 percent of the time spent counseling, but the visit only lasts the typical time, explains Greg Schnitzer, RN, CPC, CPC-H, CCS-P, audit specialist at the Office
of Audit & Compliance, University of Pennsylvania in Philadelphia.
On the other hand, a visit with more than 50 percent of time spent in counseling and coordination of care could cause it to be prolonged and beyond the typical times as established by CPT.
However, these are two separate issues, says Schnitzer. Prolonged is a length-of-time issue; coordination of care is simply a percentage of time issue. Not all greater than 50 percent of the visit spent in counseling visits end up being prolonged and not all prolonged visits are extended due to greater than 50 percent of the time being counseling, he continues.
So when do you use what?
A prolonged service code may be usedin addition to the regular EM codewhen the visit takes longer than usual for any reason. (See specific rules in cover article.)
If the majority of the visit was spent in counseling and/or coordination of care, check the typical times as outlined in the CPT and bill that level. If the time exceeds any of the levels listed, the visit may qualify for a prolonged service code.
Again, as with prolonged services, the extent of counseling and/or coordination of care must be documented. For example, if the cardiologist does only a minimal history and exam, but talks with the patient for an hour regarding an upcoming PTCA, the coder should not bill 99212 (office or other outpatient visit, established patient), plus a prolonged service code. Instead, he or she could bill a 99215, if the documentation supported it. The notes would need to say more than I spent the majority of this so-many-minute visit discussing options with the patient, says Susan Callaway-Stradley, CPC, CCS-P, senior consultant for the Medical Group of Elliott, Davis and Co., LLP, an accounting and consulting firm in Augusta, GA. The physician needs to document not only how long the conversation was but also what specifically was discussed, including the patients questions as well.
Auditors take seriously the abuse of the counseling and coordination issue, she notes. If the documentation doesnt indicate what a summary of the discussion was, including the time spent, and is lacking in exam, history or medical decision-makingand the physician still bills a higher level based on timethen he or she is upcoding.
Note: In using time as a factor in determining the level of service, CPT does not use the term counseling to mean psychiatric counseling (which would be represented by 90804-90857). Instead counseling refers to talking with patients about the following:
diagnostic results, impressions and/or recommended
risks and benefits of treatment options
instructions for treatment and/or follow-up
importance of compliance with chosen treatment option
risk factor reduction
patient and family education
The term also does not mean preventive-medicine counseling as represented by 99401-99404. The CPT states: These codes are not to be used to report counseling and risk factor reduction interventions provided to patients with symptoms or established illnesses.