General Surgery Coding Alert

Start with history, exam and MDM

Your general surgeon conducts a 50-minute established outpatient visit during which he spends 35 minutes on coordination and care. Should you report 99215, or 99213 with +99354 (Prolonged physician service in the office or other outpatient setting ...)?

CPT specifies that if counseling and coordination of care consume 50 percent or more of an E/M visit, you may use time as the determining factor when selecting an appropriate E/M level. How, then, do physicians and coders decide when to report prolonged services and when to use time to justify a higher E/M level?

Turn to History, Exam and MDM First

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 -- ut counseling and coordination of care exceed 50 percent of the time allotted to the visit -- ou 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 surgeon 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). But the surgeon 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).

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 surgeon, 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 co-ordination 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, using time as the determining factor the surgeon can report 99243 (Office consult).