Gastroenterology Coding Alert

Question: Our gastroenterologist saw a patient today for symptoms related to severe stomach cramps. The patient had been to the practice before, but not for this particular problem. After talking with her for about half an hour, the gastro discussed several nonsurgical ways she should try to improve her condition before she pursued any more serious treatment. Since he didn't examine her, how should we bill for this?

Arkansas Subscriber
 
Answer: Because counseling comprised more than 50 percent of the gastroenterologist's time with the patient, you can base the level of service on the amount of time that the gastro spent with the patient. (Remember, CPT states, "If counseling or coordination of care dominates [more than 50 percent] the physician/patient and/or family encounter, then time may be considered the key or controlling factor to qualify for a particular level of E/M service.")
 
For instance, if the physician spent 35 minutes with the patient, of which he spent only 10 minutes documenting her history and test results, and he spent the remaining 25 minutes counseling her, you can legitimately bill 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key component: