Part B Insider (Multispecialty) Coding Alert

Published on Fri Jan 08, 2010 PDF

Tighten up your documentation before you code based on time spent with patient.

Time can equal money -- if your documentation justifies the fact that counseling/coordination of care dominated your E/M visit.

"Time-based coding tends to lead to a great deal of perplexity, more so than ever due to the elimination of the consultation codes and the fact that there are no set rules or guidelines as to how to document when time is the controlling factor," says Wendy Owens-Frierson, CHM, CHI, CPC with PRSS, Inc./Avisena in Miami, Fla. "Documenting the time only does not support a valid E/M level."

If the physician spends more than 50 percent of a visit on counseling or coordination of care, you can bill for the visit based on the time the physician spends face-to-face with the patient instead of the usual medical decision-making (MDM), history, and exam.

"Documentation must include time spent face-to-face (or on floor/ unit for inpatients) counseling and/or coordinating care as well as the total time of the encounter," Owens- Frierson says.

Caveat: Documentation should include the topics discussed, and the physician should be as specific as possible. It doesn't work if you just say, "Spent 20 minutes on counseling and coordination of care."

The best occasion for this sort of billing is in a follow-up visit, when the patient has had a lab test or biopsy that revealed a problem.The visit will revolve around discussing more tests, options, and/or a plan of care.

Owens-Frierson offers the following example of potential counseling/ coordination of care documentation that could justify coding a 99214 based on time:

"Today I assessed Mr. Jones, a 96 y/o with declining Alzheimer's and colon cancer. I spent 25 minutes out of a 30 minute visit with Mr. Jones and his family discussing his declining Alzheimer's condition, reviewed labs and test results with the attending physician, and prescribed medication for tonight.

Plan: This patient requires around the clock care, and I explained to him and his family that he is a perfect candidate for hospice. The family agreed, and I wrote orders to have Mr. Jones transferred to hospice if his condition does not improve within the next 48 hours. I have contacted Dr. Smith to consult on Mr. Jones' colon cancer prior to transferring him to hospice."

Confusion abounds regarding the possibility of "rounding up." For instance, if you counseled a patient and it lasted 23 minutes, can you report a 99214 (which requires 25 minutes) or should you downcode to 99213?

Although some coders have heard that "rounding up" is acceptable from their medical societies or consultants, CMS has not published documentation that sanctions this practice, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare Solutions. Therefore, unless your carrier has instructed you in writing to  round up, you should select the lower code (in our example, the 99213.)

Plus: Expect carriers to be skeptical if you claim that a busy physician spent a whole hour with a patient, of which 35 minutes went to counseling. Some physicians include listening to patients' complaints about the magazine selection in their waiting rooms as part of "counseling," but this is wrong. That's customer service -- not counseling.

It would also appear unusual if you bill for counseling when a patient has a fairly minor diagnosis code such as a cold, but the physician claims to have spent 25 minutes. It probably won't fly unless you have many other risk factors that you're counseling. In that case,you'll have to use the different ICD-9 codes to prove the patient needed that much counseling.

It may be legitimate for a physician to bill for counseling if she spends time with a follow-up patient discussing lifestyle risks. But beware billing for such counseling in successive visits, since there are only so many times you can tell someone to quit smoking and stop eating fatty foods if he didn't listen the first time.