Pediatric Coding Alert

Remember to summarize what was discussed during counseling.

Pediatricians may spend more time counseling/coordinating care with patients than almost any other specialty, which means that your practice frequently bases E/M codes on time spent with the patient. But coding based on time can be a challenge if you don't know the three requirements of billing this way. Check out our quick primer to avoid having to send your E/M pay back to your insurers.

Case in point: See if you can spot the problem with this chart entry:

A 12-year-old girl seen for ADHD (chief complaint) FU (HPI-duration) visit. She has been on stimulant medication (HPI-modifying factor) for one month (HPI-duration) but is not doing well (HPI-quality). She is still having problems paying attention at school (social history-education) and with hyperactive behavior at home (HPI-severity). Her parents have not noted problems with appetite (ROS-constitutional) or sleep issues (ROS-neurological or respiratory-not both). Physical examination consists of a brief neurological examination (can't give credit here as there are no details). Extensive counseling is done for school and behavioral issues, her diagnosis of ADHD and treatment options (counseling description). Her stimulant dosage is increased (prescription drug management-table of risk-moderate) (MDM risk: 2 pts) and FU planned in one month. Total face-to-face time is 25 minutes (can't use this without knowing how much of that time was spent counseling).

Step 1: Include 3 Items in Documentation

Before using time as the controlling factor, check off the following requirements that must be documented:

1. the total time spent with the patient

2. that more than 50 percent of the face-to-face time the physician spent with the patient/and or family is counseling/coordination of care. For instance, "Saw the patient for 25 minutes face-to-face; 20 minutes of that visit was spent in counseling."

3. a description or summary of the counseling/coordination of care provided. For the example above, you could consider, "Done for school and behavior issues for diagnosis of ADHD and treatment options."

Problem: Although the documentation in the previous chart indicates the encounter's total face-to-face time (25 minutes), the pediatrician fails to indicate the percentage of the encounter that the physician spent on counseling and/or coordination of care.

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 and/or family member on counseling and/or coordination of care.

"For pediatricians, time is our friend," explains Richard H. Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville. "But 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."

Step 2: Use Elements When Time is Unknown

In this case, because the time spent in counseling/coordinating care is unknown, you instead have to code the visit based on the documented history, exam, and medical decision-making, as follows:

History: Detailed

• HPI-quality, severity, duration, modifying factors-Extended
• ROS: One element: Constitutional, Neuro (or respiratory-not both)
• PFSH-Social: 1 element

Exam:

None that can be used in counting the elements.

Medical Decision-Making: Low

• Est. Problem worsening-2 points
• Data-None
• Risk-Problem worsening

CODE: 99213 (History-Detailed and MDM-Low complexity).

Without knowing how much of the 25 minutes the physician spent counseling, the key documented elements support 99213, not 99214.

Solution: Adding the actual time that the pediatrician spent on counseling would indicate that the encounter meets time-based coding's greater than 50 percent on counseling/and or coordination of care criteria.

Get to Know the 'Midpoint' Coding Rule

Page xii of CPT's introductory notes say, "A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than the midpoint between zero and sixty minutes)."

Keep in mind: Although CPT directs you to "round up" to the next code after reaching the midpoint, it also advises, "When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the time closest to the actual time is used," so keep in mind that this rule trumps the "rounding up" regulation.

Time-based coding examples: You can report 99214 (25 minutes) if 20 minutes of total face-to-face time is spent with 15 minutes of counseling, and 99215 (40 minutes) can be used if you spend 35 minutes of total face-to-face time with 25 spent counseling, based on CPT's coding rules.

Differentiate 'Consult' From Time-Based E/M

Many times, a pediatric staff member will write "consultation" on a chart that includes a lot of time counseling or coordinating care. For instance, if a patient comes in for a workup after being diagnosed with cystic fibrosis, the pediatrician might spend a long time counseling the patient and discussing the prognosis with the family. However, just because the word "consultation" is on the chart doesn't mean you are meeting the requirements to report a "consult" code (99241-99245).

A true consultation occurs only when another physician or other appropriate source specifically requests the pediatrician's opinion, and the pediatrician sees the patient and subsequently writes a report back to the requesting doctor. If the pediatrician is simply seeing a patient for a standard office visit but spends most of the visit in counseling/coordinating care, you'll still bill a standard E/M code (99201-99215) based on time and not a counseling code.