Otolaryngology Coding Alert

Question: An insurer downcodes E/M visits because the diagnoses don't support the service levels that I billed. But I coded these visits based on time, not E/M elements. How can I get paid for higher-level counseling visits?

Nebraska Subscriber Answer: To document that a visit qualifies as time- based, you should note TV/C (total visit/counseling). This will show the payer that you spent the majority of the visit (more than 50 percent) counseling the patient and/or family.
 
Suppose a mother brings her 3-year-old daughter in for a six-month follow-up for allergic rhinitis (477.9, Allergic rhinitis; cause unspecified). The mother would like to consider allergy injections as an alternative to the current treatment, which includes oral histamines and nasal decongestants. The otolaryngologist performs a level-two established patient office visit (99212, Office or other outpatient visit for the evaluation and management of an established patient ... physicians typically spend 10 minutes face-to-face with the patient), which takes 8 minutes. He then spends another 20 minutes discussing the pros and cons of immunotherapy (28 minutes qualifies for 99214, ... physicians typically spend 25 minutes face-to-face with the patient).
 
Using the documentation tool, you should report 28/20, which represents 28 total-visit minutes and 20 counseling minutes. If the payer downcodes the office visit due to the diagnoses, you should appeal and submit the notes showing that you coded the visit based on time. Also indicate the counseling topic, possible immunotherapy.