Pulmonology Coding Alert

Pulmonology practices can optimize reimbursement for evaluation and management (E/M) services by documenting E/M codes based on time if the physicians counseling time with the patient comprises 50 percent or more of the entire visit.

History, examination and medical decision making are considered the key components to solid documentation for time consuming E/M services (99201-99215), says Alan Ertle, MD, MPH, of The Corvallis Clinic, P.C. in Corvallis, Ore. The basic format for E/M services recognizes seven components, six of which are used in defining the levels of E/M services, Ertle explains. The CPT lists these components as:

History
Examination
Medical decision making
Counseling
Coordination of care
Nature of presenting problem and
Time.

For an established patient, two of these three components must meet or exceed the stated requirements to qualify for a particular level of E/M services, he says. Counseling, coordination of care and nature of presenting problem are considered contributory factors in most encounters. These services are not required to be provided at every patient encounter, he explains. The level of E/M services for a new patient requires that three components be met:
Inpatient admission
Consultation and
Emergency department service

Since 1995, HCFA [the Health Care Financing Administration] has required significantly improved documentation to justify the various levels, Ertle explains. This means if you do a level 5 established office or other outpatient visit (99215), significantly more documentation regarding history, review of systems, social and family history, organ systems examined, lab and other tests reviewed and medical-decision making must be included.

The E/M codes cover a host of other things besides annual physical visits, says Nancy DeMarco Lamare, CPC, CCS-P, with Central Maine Clinical Associates in Lewiston, Maine.

What Constitutes Counseling?

The CPT 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

rognosis

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 and
Patient and family education

If an established patient comes in for a specific ailment, say for a normal x-ray for pulmonary (793.1), suggests Lamare, and he begins to ask questions, the physician can immediately discount the history exam and medical decision-making and go directly to time.

The CPT introduction states that time may be the key or controlling factor to qualify for a particular level of E/M services. This raises the level for which the visit can be billed. A 99211 visit becomes a 99213 when the physician, after five minutes of conducting the history, foregoes the physical and medical decision-making portion and spends 10 minutes counseling the patient, says Lamare. The 15 minutes is more than 50 percent of the entire visit because the 15 minutes is added to the five initial minutes, she says.

A lot of times if the physician is counseling a patient about their issues and concerns, that raises the level of visit based on time rather than on the three components, reiterates Lamare. This is especially pertinent with new patients, because with an established patient, you only have to meet two of the three criteria of history, exam, and medical decision-making. With a new patient, in order to choose a level of visit, if you go that route, you have to meet all three. If you start the visit and new patient has issues they wish to discuss, you will have to meet all three, which is more difficult. With counseling its important to know you have the option with E/M. In order to base the E/M level on time, you must document the issues discussed and the time element involved.

CPT states that if coordination of care dominates more than 50 percent the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility) then time may be considered the key or controlling factor to qualify for a particular level of E/M services.

A good time to use the counseling coordination of care is when the physician really didnt take the time to do an exam or did such a brief exam the physician cant really hit a level of service, advises Terry Fletcher, B.S., CPC, CCS-P, a coder with Health Care Coding Council in Dana Point, Calif. What they end up using is their time to hit a level of service, lets say a 99214. A 99214 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of the following components:

A detailed history;
A detailed examination; and
Medical decision making of moderate complexity.)

For an office or other outpatient visit for an established patient to be coded 99214, Fletcher says, the physician must spend 25 minutes face-to-face with the patient and/or family, and the presenting problem must be moderate-to-high in severity.

Suppose a patient returned to the physicians office after three months and the physician performed an examination, took a brief history, and then spent another 30 minutes counseling the patient. Fletcher says in this instance, prolonged services codes (99354-99357) should be used instead of outpatient counseling and coordination of care codes (99241-99245).

Using the Prolonged Services Codes

Prolonged codes (99354-99357) are used when a physician provides prolonged services involving direct face-to-face patient contact that is beyond the usual service, either in the inpatient or office visit setting. CPT states this service is reported in addition to other physician service, including evaluation and management services at any level.

Fletcher says, The codes are used to report the total durationthe actual length of timeand not a percentage of time like in coordination of care, spent by the physician. For example, 99214 would receive prolonged service code 99354, explains Fletcher, if after the physician has met two of the three key indicators followed by 30 minutes of counseling, the patient says, you know my husbands in the waiting room. Can we go ahead and go over this again? Then the physician spends another 30 minutes with the patient.

Keep in mind that the 99354 (prolonged physician service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour) is an add-on code and modifier exempt, Fletcher stresses.
What if the physician sees the patient twice in the same day? Bill the encounter with an add-on of 99354, says Fletcher, if the physician spends another 30 minutes face-to-face with the patient. The doctors time in a hospital setting can include floor time, so if the physician goes over and looks at respiratory function test or pulmonary output, discusses with the family the results, as long as the physician puts the time down he can bill for it.

Fletcher cautions that in the hospital setting a prolonged code cannot stand alone, it has to be billed with an E/M. She also reiterates that Medicare will not pay for any care that does not involve direct contact with the patient. An office/outpatient E/M code for counseling services provided to the family is based on a percentage of time greater than 50 percent. For conferences or counseling sessions that occur on different days, a separate E/M service code would be assigned instead of the prolonged services.