Oncology & Hematology Coding Alert

Question: If a provider documents total time spent on the encounter, and includes a statement that they reviewed test or labs results with the patient for a second time after reviewing them at a previous encounter, can the second review be added into the current encounter time as well?

AAPC Forum Participant

Answer: While different payers may possibly restrict this practice, CPT^® does not place a limit on how often a provider counts actions like the review of test results or counseling a patient about a specific issue.

As a reminder, CPT^® allows you to count “both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s)” toward “the total time on the date of the encounter.” Non-face-to-face time can include such activities as:

• Preparing to see the patient (eg, review of tests)
• Obtaining and/or reviewing separately obtain history
• Performing a medically appropriate exam and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other healthcare professionals (when not separately reported)
• Documenting clinical information in the electronic or other health record
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
• Care coordination (not separately reported)

CPT^® does not allow you to count non-face-to-face activity time such as:

• The performance of other services that are reported separately
• Travel

The time as described in your question could be considered counseling and educating the patient/ family or caregiver, since the provider independently interpreted the test results (which were not separately reported) and communicated those results to the patient/family/caregiver at an earlier time. In this case, it would be important for the provider to document the need to revisit that information to validate and account for the time spent.