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Pulmonology Coding Alert

Keep Your Peace of Mind:

Dont Lose Out on Counseling Payment

Published on Thu Aug 01, 2002

Tracking patient counseling and coordination of care time during an office visit can boost E/M levels and, therefore, mean more reimbursement to your pulmonology practice.

Because pulmonologists often treat chronic conditions, they frequently take on the role as a patient's primary-care physician (PCP). Consequently, they often provide counseling and coordination of care.

According to CPT, when counseling and/or coordination of care takes up more than 50 percent of the pulmonologist's face-to-face time with the patient, time may be considered the controlling factor to qualify for a particular E/M service level. The extent of counseling and/or coordination of care must be documented in the medical record, CPT states.

The AMA defines counseling as a "discussion with a patient and/or family concerning one or more of the following areas:

  • Diagnostic results, impressions, and/or recommended diagnostic studies

  • Prognosis

  • Risks and benefits of management (treatment) options

  • Instructions for management (treatment) and/or follow-up

  • Importance of compliance with chosen management (treatment) options

  • Risk factor reduction

  • Patient and family education."

    • Counseling time also includes time spent with the parties who have assumed responsibility for the patient's care or decision-making. But remember, Medicare and most third-party payers do not pay for family education without the patient present. For example, if a family member wants to talk to the pulmonologist concerning home care of the patient's chronic obstructive pulmonary disease (COPD, 496) and emphysema (492.8), Medicare requires the patient to be present in the room with the family member.

    How to Document Time

    "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 (e.g., patient response)."

    You should remember that only the physician's time spent counseling the patient can be counted toward counseling/coordination of care time. Time spent by the pulmonologist's staff on the patient's case is not reportable.

    And, the code you choose will depend on the counseling's nature. For example, if the counseling relates to a problem such as unresolved dyspnea (786.09) or asthma (493.xx), you should choose a level of service based on time from the outpatient E/M visit codes (99201-99215).

    For instance, the pulmonologist spends 20 minutes with an established patient discussing treatment options for her asthma. The physician does not perform a physical examination. Based on the counseling time involved, you should 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) linked to the asthma diagnosis (493.xx).

    Use the Three-Step Acid Test

    Mary I. Falbo, MBA, CPC,     president of Millennium Healthcare Consulting Inc., recommends the following acid 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 coordinating care?

    If all the answers are "Yes," you should specify total encounter time (in minutes).

    However, if 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, you should report one of the "Preventive Medicine, Individual Counseling" codes (99401-99404).

    For example, an asymptomatic patient comes to the pulmonologists because he has a family history of lung cancer. The doctor spends 30 minutes discussing the risks and preventive actions the patient can take to reduce his chances of personally developing lung cancer. In this case, you should report 99402 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 30 minutes) linked to V16.1 (Family history of malignant neoplasm of trachea, bronchus, and lung).

    Typically, however, Medicare does not reimburse for 99401-99404. Some private payers do, but generally only to PCPs. If your pulmonologist is not a credentialed PCP with the insurer, the preventive counseling likely will not be paid.

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