General Surgery Coding Alert

‘Counseling exception’ is key.

When your surgeon spends time counseling a patient and coordinating care during an E/M encounter, that takes time.

Don’t lose pay: You could be leaving money on the table if you don’t know how time might be on your side for choosing a higher E/M code. Take the following steps to make sure you code — and collect — for all your surgeon’s work.

Step 1: Know the ‘Counseling Exception’

You typically assign an E/M code level based on the history, examination, and medical decision making (HEM), but you can base the level on time under certain circumstances.

The relevant circumstances constitute the “counseling exception” to an E/M sick visit, in which “more than 50 percent of the total time spent in patient care involves counseling or coordination of care by the physician,” explains Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Get this: When your surgeon meets and documents that more than half a sick visit is spent on counseling and care-coordination, you should choose an E/M code based purely on the total encounter time, based on Medicare guidelines.

Example: Your surgeon performs an expanded problem focused history and exam, along with straightforward medical decision making (MDM) on a new patient with a large, painful burn on his upper thigh. This portion of the visit lasts 20 minutes. Then, the surgeon spends the next 25 minutes coordinating care with a physical therapist for hydrotherapy (whirlpool), and counseling the patient on care for the burn and management of pain.

You lose: If you were coding strictly by the standard components of history, exam, and MDM, you’d have to report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making…) for the service.

You win: Since the visit was 45 minutes long and the surgeon spent at least half of that time (25 minutes) coordinating care and counseling, the counseling exception is in effect and you can choose your code based on encounter time. For this patient, you’d report 99204 (… a comprehensive history; a comprehensive examination; medical decision making of moderate complexity…) using the counseling exception. As the descriptor for 99204 in CPT^® 2019 indicates, “Typically, 45 minutes are spent face-to-face with the patient and/or family.”

Missed opportunity: Failure to use the counseling exception can result in a lot of lost revenue. In the preceding example, you’d be missing out on almost $33, because 99202 pays $77.48, while 99204 pays $109.92 (2019 Medicare Physician Fee Schedule national non-facility amount, conversion factor 36.0391).

Step 2: Use Live Documentation to Make Exception Claims Go

Payers require documentation of time spent when you file a counseling-exception claim. “Your EHR (electronic health record) should help clinicians keep track of how much time they are spending in the exam room with patients, and document accordingly,” advises Chip Hart, a consultant with PCC in Burlington, Vermont.

“Note, though, that systems that automatically track how much time you spent with a patient are notoriously inaccurate,” Hart continues.

Do this: Encourage your surgeons to make a habit of double-checking their counseling time in real time if they think an E/M may be counseling-exception material. Then, “your system can provide an easy place to track the start and end of the counseling, giving you a better position in an audit,” says Hart.

Documentation: You must document that more than 50 percent (a majority) of the visit time was spent in counseling and coordination of care before coding based on time. “Remember that in the office/outpatient setting, only face-to-face time counts. In the inpatient setting, face-to-face and time spent on the unit focused on that patient counts,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, national director of marketing and revenue management at FasPsych in Omaha, Nebr.

Bonus: When the physician is more specific about the counseling/coordination provided for the patient, it will be a good reference for the patient’s future care, Hart says.

Step 3: Look for These Phrases on Potential Exceptions

There are no specific diagnoses that lend themselves to counseling exception E/Ms. “Almost any ICD-10 can require counseling,” Hart says. But that doesn’t mean you can’t be on the lookout for keywords and phrases that might indicate a counseling exception E/M.

Holle offers the following notes that should perk your ears up as to a potential counseling exception E/M:

• “I had a lengthy discussion …”;
• “I talked at length ….”

“Whenever they make that statement, it means they may have had a higher level of care if billed using time as a key factor,” Holle relays.

Final word: No matter how you deal with the counseling exception, the most important thing about your claim is details about total time spent face-to-face with the patient, and that the majority of the time was spent in counseling/coordination of care. “Ideally, you’d have a starting and ending time, but it doesn’t always work that way,” Hart says. But anything short of minutes spent face-to-face and minutes spent counseling really doesn’t count with payers.