Neurosurgery Coding Alert

Counseling can increase your service level, regardless of other E/M criteria If you're forgetting about coding by time for your surgeon's counseling services, you could be missing out on money your practice ethically deserves.
 
To take advantage of time-based E/M coding, however, your surgeon must provide detailed documentation to prove that she spent the majority of the patient encounter providing counseling and/or coordination of care. Time Is Key if Counseling Comprises Most of Visit You can code an E/M service based on time when the physician spends more than 50 percent of his face-to-face time with the patient providing counseling and/or coordinating care. This is a very common scenario for neurosurgeons, who may quickly reach a definitive diagnosis from MRI or CT results and then spend significant time with patients explaining their condition, answering questions, and outlining medical or surgical options.
 
Specifically, according to CPT Guidelines, if counseling and/or coordination of care constitutes more than 50 percent of the physician/patient encounter, you may use time as "the key controlling factor to qualify for a particular level of E/M services." CPT stresses, however, that to code by time the physician must clearly document the extent of counseling and the time involved.
 
Start here: For most E/M codes, CPT lists the time the surgeon usually spends rendering the service. For example, for established patient code 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...), CPT states, "Physicians typically spend 25 minutes face-to-face with the patient and/or family." This is called the "reference time."
 
How to use the reference time: Suppose your surgeon completes an expanded problem-focused history and examination on an established patient (enough for a level-three visit), but spends a total of 25 minutes with the patient and documents that he spent 18 of those minutes providing counseling. Because more than 50 percent of the visit consists of counseling, you can use the total time to determine the level of service. In this case, you could report 99214 - which pays about $35 more than 99213. Document All Times Precisely The most important part of coding by time is having complete and adequate documentation of the visit - including documentation of the total visit time and the total time the physician spends counseling, says Lynn M. Anderanin, CPC, director of coding and appeals at Healthcare Information Services in Des Plaines, Ill.
 
If you want to be able to code based on time, make sure your physicians know to document three things:
 
1. Beginning and ending time of the counseling and/or coordination of care. This is crucial to determine if the counseling accounted for more than half the visit.
 
2. Beginning and ending time for the overall face-to-face visit. "I've actually [...]