Part B Insider (Multispecialty) Coding Alert

Published on Fri Jun 04, 2004 PDF

Remember the 50-percent rule and you'll come out ahead.

An evaluation and management visit in which the physician makes the decision to go ahead with surgery will involve a lot of medical decision making, but it may be hard to document enough to justify a high-level visit.

That's why you should consider billing for these modifier -57 visits using the counseling and coordination care rule instead, says consultant Quinten Buechner with Proactive Consultants in Cumberland, WI. Often, a lot of time is spent in these visits discussing the surgery with the patient, who may need to discuss scary topics like "the possibility of dying on the table," says Buechner.

To make this work, "you've got to have documentation of the time used and what was discussed," says Buechner. "Surgeons have a tendency to spend a lot of time but not necessarily document the time."

Usually, the time-based approach is an exception and the use of the three components (history, physical and MDM) is the rule, says consultant George Alex with Iatro in Baltimore, MD. If you feel as though the physician spent enough time on counseling and coordination of care to justify time-based billing, you'll have to find documentation that supports it. For example, in an inpatient setting, the documentation must show that the physician spent greater than 50 percent of his time on the floor or unit on counseling.

In fact, if the physician spent a lot of time making the decision to perform surgery, that may count as MDM instead of counseling, notes Alex. In that case, you'd be better off billing based on the three elements. To show that this isn't the case, the physician's notes should say that after the decision to perform surgery, a "significant amount of time was spent discussing the surgical option with the patient," says Alex.

And any documentation of that discussion must be detailed. "You want to show what you were doing when you were counseling or coordinating care," says Alex. "You want to say [you were] discussing any questions the patient may have, and also making arrangements for necessary surgery." This could also include calling in an anesthesiologist on some topics. If the physician was discussing the benefits or risks of surgery with the patient, that definitely counts as well.