Orthopedic Coding Alert

You might be able to code E/M based on time … in certain situations.

Patients that report to the orthopedist for an evaluation and management (E/M) service can, from time to time, require more counseling or care coordination than is typically required for the E/M code that you are considering.

When this occurs, you might be able to choose an E/M code based strictly on the amount of time the physician spends coordinating care and/or counseling the patient, confirms Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Caution: You’ll have to be wary of miscoding when using this so-called “counseling exception”; so we got a couple of experts together to soothe your counseling exception concerns.

Make 50 Percent Mark Before Considering Exception

By strict definition, the “counseling exception is an E/M sick visit [in which] more than 50 percent of the total time spent in patient care involves counseling or coordination of care by the physician,” explains Holle.

When the above parameters are met, you can choose an E/M code based purely on the total encounter time. So let’s say the orthopedist performs an expanded problem focused history and exam, along with straightforward medical decision making (MDM), on a new patient with a sore elbow. This portion of the visit lasts 20 minutes. Then, the physician spends the next 25 minutes coordinating care with a physical therapist and counseling the patient on care for her injury.

Wrong way: If you were coding strictly by the standard components of history, exam, and MDM, you’d have to report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making … ) for the service.

Right way: Since the visit was 45 minutes long and the physician spent at least half of that time (25 minutes) coordinating care and counseling, the counseling exception is in effect and you can choose your code based on encounter time. For this patient, you’d report 99204 ( … a comprehensive history; a comprehensive examination; medical decision making of moderate complexity …) using the counseling exception. As the descriptor for 99204 in CPT^® 2019 indicates, “Typically, 45 minutes are spent face-to-face with the patient and/or family.

As you can see, failure to use the counseling exception can result in a lot of lost revenue. And knowing when to use the counseling exception is only half the battle, experts say.

Live Documentation a Must to Make Exception Claims Go

Obviously, payers are going to want to see some proof of time spent on counseling exception claims. This means “your EHR [electronic health records] should help clinicians keep track of how much time they are spending in the exam room with patients and document accordingly,” relays Chip Hart, a director at PCC Consulting Group in Vermont

“Note, though, that systems that automatically track how much time you spent with a patient are notoriously inaccurate,” continues Hart.

Try to get clinicians into the habit of double-checking their counseling time in real time if they think an E/M may be counseling exception material. Then, “your system can provide an easy place to track the start and end of the counseling, giving you a better position in an audit,” says Hart.

Holle agrees, saying “the issue here is that the physician has to document the total amount of time in the visit and the percent spent in counseling and what they counseled on,” explains Holle. “The total time, amount of time in counseling/coordination, and what was counseled/coordinated has to be documented. Without any of those you cannot bill based on time.”

As an added bonus, when the provider is more specific about the counseling/coordination she provided for the patient, it will be a good reference for the patient’s future care, Hart says.

Look for These Phrases on Potential Exceptions

As Hart points out, there are no specific diagnoses that lend themselves to counseling exception E/Ms. “Almost any ICD-10 can require counseling,” he says. But that doesn’t mean you can’t be on the lookout for keywords and phrases that might indicate a counseling exception E/M.

Holle offers the following notes that should perk your ears up as to a potential counseling exception E/M:

• “I had a lengthy discussion …”;
• “I talked at length … ”

“Whenever they make that statement it means they may have had a higher level of care if billed using time as a key factor,” Holle relays.

Final word: But no matter how you deal with the counseling exception the most important thing about your claims is details about the minutes spent counseling, Hart says. “Ideally, you’d have a starting and ending time, but it doesn’t always work that way. But anything short of ‘XX minutes spent counseling’ really doesn’t count” with payers, he explains.