Gastroenterology Coding Alert

Increase your E/M by an entire level or more with proper documentation

You don't have to allow lengthy but low-level E/M visits or time spent reassuring and counseling patients to go under-reimbursed. Improve your E/M efficiency immediately by taking advantage of CPT's -time clause.-
 
Key fact: Under certain circumstances, you can use time -- rather than the key E/M components of history, exam and medical decision-making (MDM) -- to determine an E/M service level, thereby allowing the physician to report a higher-level code than would be warranted by the key components alone.

Meet the 50 Percent Threshold

You may consider time to be -the key or controlling factor to qualify for a particular level of E/M services- when counseling and/or coordinating care dominates the physician/patient encounter (in other words, when counseling and/or coordination of care consumes more than 50 percent of the visit), according to CPT guidelines.
 
Counseling and coordinating care could include discussion with the patient (or his family) about one or more of the following, CPT guidelines specify: diagnostic results, impressions and/or recommended diagnostic studies, prognosis, risks and benefits of treatment options, instructions for treatment and/or follow-up, importance of compliance with chosen treatment options, risk-factor reduction, and patient/family education.
 
Example: An established consult patient with a possible diagnosis of colon cancer (for example, 153.x, Malignant neoplasm of colon) returns to the gastro-enterologist's office to discuss the results of a previous colonoscopy. The GI physician and patient spend an hour discussing test results and treatment options. The history, exam and MDM are minimal in this case, but because counseling and coordination of care dominate the encounter, you can use time as the controlling factor in assigning the E/M service level.
 
Check the -Reference Time-

To determine the appropriate E/M level for a given amount of time spent with the patient, you must check the -reference time- included in the CPT descriptor for codes that best describe the service the gastroenterologist provides, says Barbara Oviatt, CPC, CCS-P, coding manager for Martin Memorial Medical Group in Stuart, Fla.
 
For instance: The descriptor for 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) states, -Physicians typically spend 10 minutes face-to-face with the patient and/or family.- On the other hand, the descriptor for 99254 (Initial inpatient consultation for a new or established patient ...) states, -Physicians typically spend 80 minutes at the bedside and on the patient's hospital floor or unit.-
 
Don't forget: To qualify for a given level of E/M service, the physician must spend at least half the total time (which should meet or exceed the reference time of the chosen code) on counseling and/or coordinating care, Oviatt says.
 
Therefore, if the gastroenterologist documents that she spent six minutes of a 10-minute office visit on counseling and coordination of care, you may report 99212. Likewise, if the doctor dedicates 65 minutes of a 90-minute initial inpatient consult to counseling and coordination of care, you may bill 99254.
 
Important: Time the physician spends taking the patient's history or performing an examination does not count as counseling time. The physician must look at the entire patient encounter and decide if he spent the majority of time in counseling and/or coordinating care or if the key components of history, exam and MDM should be the deciding factor when choosing an E/M level.
 
Returning to the above example of the consult patient, for a one-hour visit you may report 99244 (Office consultation for a new or established patient ...), which has a reference time of 60 minutes, because at least 50 percent (that is, 30 minutes) of the visit (minus the time required to take the history and exam) involved counseling and/or coordination of care.

The Physician Must Document

To support a time-based E/M service, the physician should specifically note start and stop times for the patient visit, as well as the portion of the time spent on counseling and coordination of care, says Lynn M. Anderanin, CPC, director of coding and appeals at Healthcare Information Services in Park Ridge, Ill. CMS guidelines require physicians to document exact times, and your practice may have trouble during an audit if physicians don't note this information.
 
In addition, the physician should note the issues discussed during counseling (for example, treatment options, prognosis, etc.). For instance, the physician might note, -20 minutes with patient discussing possible treatment options and lifestyle/diet modifications for irritable bowel syndrome [564.1].-
 
Play it safe: If your physician does not include enough information about the patient's visit, you may have no choice but to code a lower-level service.
 
A final note: The physician should include the components of history, exam and MDM -- even if cursory -- in the documentation. Good medical record keeping requires that you document relevant and pertinent information. Using time as the determining factor to choose the E/M level does not negate this requirement.