Pediatric Coding Alert

Question: The 2021 revisions to the office/outpatient evaluation and management (E/M) codes no longer contain language stating that time spent counseling the patient and/or family can be counted toward total time when billing the encounter on time. Does this mean that a pediatrician can no longer meet with a parent alone, without the patient present, and continue to bill based on total time?

Massachusetts Subscriber

Answer: When the AMA revised CPT^® office/outpatient E/M codes 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) on Jan. 1, 2021, they deleted the following language in the code descriptors:

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of XX severity. Typically, XX minutes are spent face-to-face with the patient and/or family (emphasis added).

This has led some to wonder if the removal means a pediatrician can no longer meet with a parent or caregiver without the patient present and bill based on total time, which CPT^® defines as “the face-to-face time with the patient … unless there are code or code-range-specific instructions in guidelines, parenthetical instructions, or code descriptors to the contrary” (Source: CPT^® Manual, p. xvii).

In fact, the 2021 guideline revisions do contain such code-range-specific instructions for 99202-99215 when using time for code selection. These state, in part, that “physician/ other qualified health care professional time includes … counseling and educating the patient/family/caregiver … when performed.”

This implies that you can count time spent counseling or educating the patient’s family and/or caregiver whether or not the patient is present — in other words, that the revisions have not changed the policy as it previously existed.

However, it is important to note, as always, that private payers may interpret these guidelines differently, and may insist that the patient be present during the encounter in order for you to be reimbursed for the office/outpatient E/M service when you have determined the level for the service by time.