Part B Insider (Multispecialty) Coding Alert

Published on Fri Jan 15, 2010 PDF

Question: I read your article on coding E/M services based on time from last week's Insider and I have a follow-up question. Our doctor documented 60 minutes on an established patient's office visit. He diagnosed the patient with morbid obesity (278.01) and new onset uncontrolled type II diabetes mellitus (250.02). Since the patient was newly diagnosed and had some difficulty understanding the doctor's orders, the physician spent more than half the office visit time on counseling on therapeutic lifestyle changes and the treatment regimen. Should I code this as 99214 for the first 25 minutes and +99354 for the remaining time?

Answer: No. Because counseling and/or coordination of care takes up the majority of this office visit's time (counseling represents more than 50 percent of the total time with the patient), you should choose the level of E/M service based on time. You would assign 99215 (Office or other outpatient visit for the evaluation and management of an established patient...) for this office visit.

Consider this: When the doctor spends more than 50 percent of an E/M service on counseling and/or coordination of care in a face-to-face encounter, select an E/M code based on the typical/ average time associated with the code levels, reports the Medicare Claims Processing Manual (MCPM), chapter 12, section 30.6.15.1H. The time approximation must meet or exceed the specific

CPT code you report, which is determined by the typical/average time associated with the E/M code.

Example: A physician provided a subsequent office visit that was predominantly counseling, spending 60 minutes (face-to-face) with the patient, continues the MCPM. The physician cannot code 99214 (which has a typical time of 25 minutes) with one unit of code 99354.

The physician must bill the highest level code in the code family (99215, which is associated with 40 minutes typical/average time units). The additional time the physician spends beyond this code is 20 minutes, which does not meet the prolonged service code +99354's "threshold" time of 30 minutes. You don't need to report a prolonged service code in this situation.