Internal Medicine Coding Alert
Use Counseling Time To Code Higher-Level E/M
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According to Scott Manaker, MD, an internist at University of Pennsylvania Hospital in Philadelphia, if a physician spends 25 minutes with a patient (established), of which only five minutes was used to document a low-level history (no physical exam was necessary) and the remaining 20 minutes was counseling, the doctor can legitimately bill 99214 (office or other outpatient visit for the evaluation and management of an established patient ... physicians typically spend 25 minutes face-to-face with the patient and/or family).
Face-to-face is defined as the one-on-one time the physician spends with the patient alone or the patient and family together, including obtaining a history, performing an examination and counseling. However, during this visit, time can also be reported for reviewing records and tests, arranging for further services, and communicating, either in writing or by telephone, with other professionals and the patient (as long as the patient is present).
Another important item to note is that Medicare requires the patient's presence during counseling with the family. And, Medicare wants the medical record to indicate what was discussed during the encounter. The discussion with the patient and/or the patient and his or her family should cover one or more of the following:
Counseling During Regular Office Visit
Michael Haynes, MD, an internist and compliance director for University Medical Associates in Augusta, Ga., says that counseling often precedes other office visit services. For example, particularly in Haynes' sub-specialty of pulmonology, patients frequently come in to discuss complex test results, such as a biopsy that reveals cancer. Treatment options and the relative risks associated with them are discussed. In this case, the patient's options could be surgery, radiation or chemotherapy. The physician must determine what path the patient wishes to follow.
For example, an internist follows up with an established patient, an 80-year-old woman who had recently been seen for a lump she discovered in her breast. Her concerned family accompanies her to this follow-up visit to learn the results of the biopsy.
The physician reviews with the patient the biopsy results, which confirm a diagnosis of cancer. The internist then takes a comprehensive history, performs an extensive exam, and tells the patient that, based on the biopsy results and the exam, surgery is necessary. The examination took 10 minutes, but, because of the family's concern about the risks associated with the surgical procedure, the physician spends the next 40 minutes counseling the patient and her family.
The next 10 minutes is spent on the phone with a surgeon discussing the case, setting up a referral, and arranging for the surgery. The entire encounter takes 60 minutes, 50 of which are devoted to counseling and coordination of care. Therefore, select a code listing 60 minutes as an average time (99215) because the time spent counseling and coordinating care was more than 50 percent of the encounter's face-to-face time.
Haynes says that often an established patient with a known medical problem will not show any signs of illness related to that problem but might need counsel regarding a new complaint. Because the patient presents with a new problem, the E/M service is based on the new problem and time spent counseling.
For example, a 55-year-old woman with hypertension comes into the office and, although her blood pressure is fine, explains how a family member was recently diagnosed with breast cancer and she is concerned about her own risk. Aside from the routine blood-pressure follow-up, the internist performs a separate workup by examining her breasts and reviewing her last pelvic and breast exam. The internist spends more than 50 percent of the time discussing the risks and treatments of breast cancer. The E/M level is based on the time spent counseling because it exceeded 50 percent of the visit.
Counseling During Consultations
Haynes says that sometimes counseling dominates a consultation visit as well. A consult is provided by a physician whose opinion or advice of a specific problem is requested by another physician.
For instance, a primary care physician (PCP) refers a patient diagnosed with sleep apnea to an internist who specializes in sleep disorders. The PCP orders a sleep study (95805-95829, 95920-95925 and 95950-95962) first and sends it to the internist to read. The internist bills separately for the interpretation of the sleep study, attaching modifier -26 to the code to indicate professional component only. He then schedules an appointment with the patient to discuss the results. The visit lasts 40 minutes.
"Here the physical part of the exam is relatively trivial," Haynes says. "It's time spent discussing the therapeutic treatment options that matters most." The internist would probably bill 99243 (office consultation for a new or established patient. Physician spends 40 minutes face-to-face with the patient and/or family).
Using Preventive Codes for Counseling
Sometimes patients come in to discuss issues unrelated to their current medical complaint. In these cases use the preventive-medicine individual counseling codes 99401 (preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure], approximately 15 minutes), 99402 ( ... approximately 30 minutes), 99403 ( ... approximately 45 minutes), 99404 ( ... approximately 60 minutes), 99411 (preventive medicine counseling and/or risk factor reduction intervention[s] provided to individuals in a group setting [separate procedure]; approximately 30 minutes) and 99412 ( ... approximately 60 minutes).
However, it is very likely that a payer will want extra documentation to ensure these services meet the code definition because a non-psychiatrist is submitting them. And, because most payers do not usually reimburse preventive-counseling services, the patient should know this before scheduling an appointment. He or she must agree to pay if the carrier does not cover the service.
For example, a 35-year-old male with a family history of heart disease is counseled for 45 minutes on preventive measures, including diet and exercise. This visit should be coded 99403.
Use 99401-99412 to report counseling provided to individuals at a separate encounter for issues such as family problems, diet and exercise, substance abuse and sexual practices. Do not use these codes to report counseling and risk-factor-reduction services provided to patients with symptoms or illnesses.
Coding for Prolonged Counseling
A prolonged-service code may be used in addition to the regular E/M code when the visit takes longer than usual for any reason. If the majority of the visit was spent in counseling and/or coordination of care, check the typical times as outlined in CPT and bill that level. If the time exceeds any of the times in the levels listed, the visit might qualify as a prolonged service.
For office visits that involve face-to-face patient counseling beyond the usual time as described in CPT 2001, use 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour) and, if appropriate, 99355 (... each additional 30 minutes). These are time-based, add-on codes intended only to accompany codes for other physician services provided on the same date, for example an E/M visit at any level. Time spent does not have to be continuous.
For inpatient settings, apply the same rules and use 99356 (... in the inpatient setting ... ; first hour) and 99357 (... each additional 30 minutes). And, when counseling does not involve face-to-face contact, for example, reviewing extensive records before and after a patient visit or talking with other professionals, use 99358 for the first hour and 99359 for each additional 30 minutes.
Haynes and Manaker agree that internists rarely use these codes, but there are exceptions. For example, Haynes described a case in which he spent more than 40 minutes explaining a procedure to a patient. The patient then asked if he would repeat the process to the family sitting in the waiting room. Haynes repeated the process and spent another hour in addition to the initial counseling session.
Manaker says that sometimes discussing a particular procedure, such as the many controversies surrounding the various treatments for prostrate cancer, dictates using prolonged-service codes. "While Medicare might pay for prolonged services, other carriers might not," he says. Again, check with each specific carrier to determine
payer guidelines.
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