Pediatric Coding Alert

Providers play a vital role in counseling exception coding success.

Pediatric practices that have success coding for counseling exception evaluation and management (E/M) services all have one thing in common: solid communication between coders and providers.

Why? Coders need a specific set of details documented in order to successfully apply the counseling exception, which allows you to select an E/M code based on time rather than the three key components of history, examination, and medical decision making (MDM).

The providers are charged with providing these details on the encounter forms, coding experts say.

According to Donelle Holle, RN, President of Peds Coding, Inc, and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, coders need to consider several pieces of information prior to even considering a counseling exception E/M:

• “Physicians have to document the total amount of time in the visit and the percent spent in counseling  — and what they counseled the patient on,” Holle explains. This time record must be exact.
• “They cannot estimate counseling time; they cannot say ‘Spent 30 minutes in counseling,’ as that doesn’t mean anything as to the total time,” explains Holle.

Bottom line: Your counseling exception E/M claims must include documentation that reveals:

• total E/M time;
• amount of time spent counseling/coordinating care (which must be at least 50 percent of the total E/M time); and
• what the provider counseled the patient on.

This information has to be in the documentation for coding success for counseling exception claims. “Without any of those pieces of information, you cannot bill based on time,” Holle says.