Pediatric Coding Alert

Think 35 minutes spent on a counseling-dominated visit is a 99214? CPT has a different answer you might want to consider.

You could say 99215 if you consider the times listed in the codes' descriptors as averages, rather than thresholds. Which is right? It depends on which guidelines you follows

"Medicare says these times are minimums," says Patricia A. Trites, MPA, CHBC, CPC, EMS, CHCC, CHCO, CHP, CMP, CEO of Healthcare Compliance Resources in Augusta, Mich.

Why it matters? Pediatricians have to follow Medicare's interpretation when reporting to any federal program, such as Medicaid or TriCare, Trites says. Because choosing a level per payer is tricky, she recommends following Medicare's guideline and considering the times as minimums.

Here's how: The physician would select the lower code (for instance 99214, ... physicians typically spend 25 minutes face-to-face with the patient and/or family ...) unless the time was greater than or equal to the higher-level code's required time (such as 40 minutes for 99215). "I have always considered the allotments as thresholds," agrees Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville.

"The AMA says you can use the code closest to the documented time," Trites also points out.

"In selecting time, the physician must have spent a time closest to the code selected," states CPT Assistant, Aug. 2004.

How it works: "Your documented time must equal or exceed the 'average' time given to bill that level," explains F Tessa Bartels, CPC, CPC-E/M, reimbursement manager for pediatric surgery/craniofacial remodeling at Medical College of Wisconsin in Milwaukee. "You bill based on total time spent (not just the amount of time spent in counseling)," she stresses.

You would select the higher-level code if the face-to-face time is more than half of the time difference and more than 50 percent of the time is spent on counseling and/or coordination of care, the AMA describes. Following the AMA's closest time code rule, time breakdowns for office visits include:

Try Your Hand

Compare the two methods in calculating the following scenario. "I spent 35 minutes with patient, 20 minutes of which was for counseling regarding weight management, helping to formulate a diet and exercise plan."

Method 1: When considering the time allocations as thresholds, this would be a 99214, Bartels says.

Method 2: The American Academy of Pediatrics (AAP) indicates you could instead select 99215 when time spent is 33 minutes or longer, according to AAP News July 2008.