Primary Care Coding Alert

Counseling time also includes time spent with the parties who have assumed responsibility for the patient's care or decision-making. But Medicare and most insurance companies do not pay for family education without the patient present. If, for example, a family member wants to talk to a doctor concerning a patient's diabetes and the risk it poses to the patient's eye health (250.5x, Diabetes with ophthalmic manifestations), Medicare requires the patient to be present in the room with the family member for it to reimburse for the visit.

1. Determine How the Documentation Measures Up

"The physician should document the total visit time and how much of that time was spent counseling/coordinating care," says Carol Pohlig, BSN, RN, CPC, reimbursement analyst for the department of medicine at the University of Pennsylvania in Philadelphia. "The physician should also comment on the important issues discussed with the patient in addition to any relevant clinical information, such as the patient's response."
 
Don't forget that only the physician's time spent counseling the patient can be counted toward counseling/coordination of care time. Time spent by the physician's staff on the patient's case is not reportable. Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. of Lansdale, Pa., recommends the following test for compliant documentation when billing based on time:
 
1. Does the documentation reveal the total face-to-face  time in the outpatient setting or on the unit/floor in the  inpatient setting?
 
2. Does the documentation describe the content of the   counseling or coordination of care?
 
3. Does the documentation reveal that the physician    spent more than half of the time counseling or coordi-  nating care?

If all of the answers are "Yes," you should specify total encounter time (in minutes). Some insurance carriers ask for specific documentation that shows the time the counseling began and ended, so a best practice for your physician is to be as specific as possible.

2. Link the Face-to-Face Time to the Diagnosis

When counseling is part of a new patient visit, report 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient) depending on the complexity of the patient's problem and the time the patient spends with the physician.
 
For instance, if a doctor sees a new 65-year-old female patient for chest pain after exertion (786.50) and spends 45 minutes face-to-face with her and uses 25 minutes of that 45 minutes counseling the patient on diet and lifestyle, you should report 99204 and link it to 786.50.
 
If the physician counsels an established patient for a new or an ongoing problem and spends more than 50 percent of the face-to-face time counseling the patient, report the established patient office visit codes (99212-99215) based on time.
 
For example, a doctor spends 20 minutes face-to-face with an established patient and uses 12 minutes of the encounter to discuss treatment options for diabetes (250.xx). Report 99213 (Office or outpatient visit for the evaluation and management of an established patient ... Physicians typically spend 15 minutes face-to-face with the patient and/or family) and link it to the appropriate diabetes diagnosis code (250.xx).
 
If a nonphysician practitioner (NPP) counsels the patient, use a code from the range 96150-96155, which are health and behavior assessment and intervention codes for patients who need counseling for physical health problems. These codes are in the medicine section of CPT.
 
For example, a 60-year-old female patient with hypertension (401.x) is having difficulty keeping her blood pressure down and sees an NPP with expertise in hypertension management. In this case, you should report the appropriate code from 96150 to 96155 depending on the time spent with the patient, whether the counseling is for an individual or a group, and whether the family was present during counseling.

3. Use Risk-Reduction Codes

If the patient sees a physician just for counseling and does not have an established illness, you should use 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes), 99402 (... approximately 30 minutes), 99403 (... approximately 45 minutes) or 99404 (... approximately 60 minutes), depending on the counseling session's duration. Indeed, the preventive, risk-reduction counseling codes are not the same as those for counseling patients with established medical problems, so make sure the documentation notes are clear regarding the reason the physician is counseling the patient, coding experts say.
 
Use codes 99401-99404 when the patient does not have any signs, symptoms or problems - acute or chronic, stable or unstable - and the counseling concerns health maintenance or prevention (in the absence of disease or injury), such as smoking cessation or exercise.
 
For instance, an asymptomatic patient comes to a physician because he has a family history of colon cancer (V16.0). The physician spends 30 minutes discussing the risks of the disease and preventive actions, such as special diets or vitamin supplements that the patient can take to reduce his chances of developing colon cancer. In this case, you should report 99402 linked to V16.0 (Family history of malignant neoplasm; gastrointestinal tract).
 
Typically, however, Medicare does not reimburse for 99401-99404. Some private payers do, but generally only to primary-care physicians (PCPs) with whom they have an established contract for certain preventive services. If your physician is not an insurer-credentialed PCP, you're not likely to receive reimbursement for the preventive counseling.