Gastroenterology Coding Alert

Question: How should I choose between coding a time-based E/M service code or prolonged services?


California Subscriber

Answer: Generally, you should assign E/M levels according to the key components of history, examination and medical decision-making (MDM). Then, if the physician spends 30 minutes or more beyond the reference time of the chosen E/M level on counseling and coordination of care, you can use the prolonged services codes.

If the physician spends fewer than 30 additional minutes beyond the reference time of the appropriate E/M level (as determined by history, exam and MDM) with the patient--but counseling and coordination of care exceed 50 percent of the time allotted to the visit--you may choose to code a higher E/M level based on time.

Document and be honest: As long as the physician does not attempt to misrepresent the services provided, he deserves to be reimbursed for additional time spent with a patient.

Coding example: During an office visit, the gastro-enterologist tells an established patient that he has a new diagnosis of colon cancer. Based on the components of history, examination and MDM, the visit warrants a level-two visit (99242, Office consultation for a new or established patient ...). But the physician spends an additional 40 minutes (beyond the 30-minute reference time) discussing treatment options with the patient.

In this case, report the consult (99242) and one hour of prolonged services (+99354, Prolonged physician service in the office or other outpatient setting ...).

If the same patient presents for the same consult but requires only 20 additional minutes (again, beyond the 30- minute reference time for 99242) with the physician, you may not report prolonged services. If the physician spends 30 minutes of a 50-minute consult (in other words, more than 50 percent of the visit) on counseling and coordination of care, you may use time as the key component when assigning the E/M level. Although the components of history, examination and MDM make the visit a level-two consult, by using time as the determining factor the physician can report 99243 (a level-three consult).