Pediatric Coding Alert

Let these three answers guide your time-based E/M coding quandaries.

Pediatricians are masters at listening to worried parents, scared children, or other concerned caregivers. Those minutes spent talking to parents can be lengthy, but it isn’t wasted time since it assists you in diagnosing the patient and helps the patient understand his condition and how to get better. You can collect for that valuable time by utilizing time-based E/M coding to your advantage. Consider the answers to these commonly-asked questions to help you collect the appropriate payments for your evaluation and management visits.

‘Shall’ Doesn’t Mean ‘May’

Question 1: How do we know if we should code using time as the determining factor versus using history, exam, and medical decision-making? Our pediatrician sees a lot of kids with special needs and ostensibly we could be coding mostly 99215s if we coded them all based on time, but we aren’t sure when we should.

Answer 1: You should always code based on time if you meet the criteria. That’s not just an opinion—that’s straight from CPT^®.

In black and white: “When counseling and/or coordination of care dominates (more than 50 percent) the encounter with the patient and/or family (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for a particular level of E/M services” (emphasis added).

Note the fact that CPT^® uses the word “shall.” This appears to be dictating that you should use time as the determining factor in selecting your E/M level rather than just having the option to do so.

Example: A nine year-old boy is seen for an ADHD follow-up visit. He has been on stimulant medication for six months but his parents feel it is having negative side effects. Although his behavior is more calm at school, he has lost 10 pounds from failure to eat, and is always tired at home. Physical examination consists of a brief neurological examination. Extensive counseling is done for school and behavioral issues, his diagnosis of ADHD and treatment options. His stimulant dosage is decreased by five milligrams and follow-up planned in one month. Total face-to-face time is 25 minutes with 15 minutes spent counseling/coordinating care.

For this visit, you should report 99214 because the visit lasted 25 minutes and at least half of that time was spent counseling/coordinating care.

Don’t Add Phone Call Time to Same-Day E/M

Question 2: I know that most insurers don’t pay for phone calls, but it’s becoming increasingly common for parents to contact our office the same day of a sick visit for more information after they’ve either thought of additional questions or forgotten the advice we’ve given. For instance, we saw a diabetic patient last week and we spent 18 minutes out of a 25 minute visit counseling the patient about her insulin use. That afternoon, the mother called and said she’d been researching alternative treatments on the internet and wanted to ask me about them. We spent another 15 minutes on the phone discussing this. Can I add that time on the phone to the time spent during my E/M visit?

Answer 2: Unfortunately you cannot add the time spent on the phone to the time you spent at the visit earlier in the day, because the telephone time did not involve a face-to-face visit.

In addition, you could not report the telephone codes because you can only bill those if the call involves an unrelated issue. You cannot report a telephone service code if the call takes place within seven days of a recent previous visit, a surgical or diagnostic procedure, or a scheduled upcoming E/M service. CPT^® considers these part of a previous or upcoming visit and billable as part of the subsequent E/M code chosen.

Two Patients Deserve Two Records

Question 3: Can we bill based on time if we see two patients during the same visit? For instance, I spent 50 minutes in a room counseling a parent who brought in her two kids, both of whom are chronic asthmatics. One of the sisters also had bronchitis and the other had sinusitis. We talked for 30 minutes about appropriate use of the nebulizer preemptively because the parent had never used it. We also talked about getting the children appropriate winter gear so they wouldn’t be breathing in cold air when they walked to the bus stop, and other issues related to their asthma. The counseling took up about 15 minutes for each child.

Answer 3: You can bill for this visit based on time, but you should create two separate encounters for the siblings and count only the time spent for each patient. For example, if you spent 25 minutes with each and counseled each for 15 minutes, you’d bill 99214 for each patient and write the documentation separately, including how much total time was spent, how much time was spent counseling, and what was discussed for each patient in their visit encounter.