Oncology & Hematology Coding Alert

Question: The oncologist documented 60 minutes for an established patient office visit. She documented spending more than half the time on counseling because they were discussing treatment regimen options and the patient had many questions. Should I code this as 99214 for the first 25 minutes and +99354 for the remaining time?

Minnesota Subscriber

Answer: No. When counseling and/or coordination of care represents more than 50 percent of the total time with the patient, CPT guidelines instruct that you may choose the E/M level based on time. You should  assign 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity ... Physicians typically spend 40 minutes face-to-face with the patient and/or family) for this office visit.

How it works: When the physician spends more than 50 percent of an E/M service on counseling and/or coordination of care in a face-to-face encounter, select an E/M code based on the typical/average time associated with the code levels, reports the Medicare Claims Processing Manual (MCPM), Chapter 12, Section 30.6.15.1.H. The documented time must meet or exceed the typical/average time associated with the E/M code you report (as stated in the code definition).

For instance: The MCPM offers an example of a physician providing a subsequent office visit that was predominantly counseling, spending 60 minutes (faceto- face) with the patient. The physician must not code+99354 (Prolonged physician service ...) and 99214 (which has a typical time of 25 minutes). The physician must bill the highest level code in the code family (99215, which is associated with 40 minutes typical/average time units). For a 60-minute visit, the additional time the physician spends beyond 99215's 40 minutes is 20 minutes, which does not meet the 30-minute minimum CPT guidelines indicate +99354 requires. So you should not report a prolonged service code in this situation.