Part B Insider (Multispecialty) Coding Alert

Published on Tue Sep 09, 2008 PDF

Counseling, coordination of care count toward E/M time.

You've got a nifty tool to capture higher-level office visit codes when your physician provides mainly counseling to a patient.

Overlooking CPT's time rule will land you with lower-level codes for visits involving mainly counseling and little-to-no history, examination, and/or medical decision-making. To start benefiting from using time as the controlling factor, check out these tips.

Before using time as the controlling factor, check off the following requirements. To code based on time in the office setting, the physician must document:

1. That more than 50 percent of the face-to-face time the physician spent with the patient is counseling and/or coordination of care, says Lisa Curtis, CPC-I, CPC-E/M, who specializes in E/M audits in the Greeley, Colo. area. "I advise my providers to state the actual time (for instance, 45 minutes was spent with the patient in total, 30 minutes in counseling)."

Why: An auditor needs to be able to tell the percent of the visit that the physician spent on counseling and/or coordination of care, explains Patricia A. Trites, MPA, CHBC, CPC, EMS, CHCC, CHCO, CHP, CMP, CEO of Healthcare Compliance Resources in Sherman, Tex. CPT lets you select an office visit code based on time only when the physician spends more than 50 percent of the face-to-face time with the patient on counseling and/or coordination of care. If documentation does not specify that the encounter has met the more than 50 percent counseling requirement, you cannot use time as the controlling factor to select the level of E/M service.

2. A description or summary of the counseling/coordination of care including, for instance, the topic, advice given, and recommendations.

"The physician just can't say 'had a long discussion about X,'"Trites warns. "That won't work."

3. The total time spent with the patient and/or family. If you code based on time, you'll use this number to select the E/M level.

If the encounter and documentation do not support the above items, switch from using time as the controlling factor.

How: You instead have to code the visit based on the documented history, examination, and medical decision-making.

Not sure when you'd use time-based coding? Any time a patient and/or family see the doctor for counseling, the encounter might qualify. Think counseling for cases, such as chronic arthritis or obesity, in which your physician spends the majority of the visit explaining conservative steps, surgical options, risks, etc.

Example: An established patient presents to your office to discuss the results of previous testing. The physician and patient spend 30 minutes discussing test results, available treatment options, risks, and benefits.

Solution: The history, exam, and medical decision-making are minimal in this case, but because counseling and coordination of care dominate the encounter, you can use time as the controlling factor in assigning the E/M service level.

Provided the physician summarizes the counseling, you would select the E/M code based on time and report 99214 (Office or other outpatient visit for the evaluation and management of an established patient ... ... physicians typically spend 25 minutes face-to-face with the patient and/or family ...).

Here's why: Going over test results, discussing surgical options, and coordinating surgery counts under counseling. Counseling consists of the physician discussing with the patient and/or family one or more of several areas including diagnostic results, prognosis, risks and benefits of management (treatment) options, or importance of compliance with chosen management (treatment) options, according to the E/M services guidelines outlined in CPT.