I have a physician that wants to code a office visit by time however the patient has a chief complant "stiffness along the paraspinal muscles". The physician did a Expanded Problem Focused hx and exam but then spent 25 minutes with the patient so he wants to charge 99214 based on time instead of 99213 based on h&p. Can he charge based on time with a chief complaint?
When counseling/coordination of care take up the bulk of the visit (meaning that they take up at least half of the total face-to-face time), the physician may select the CPT code based solely on time. The content of the counseling and/or coordination of care efforts must be documented, and the amount of time spent in counseling/CoC must be listed, as well. (That's not to say that the other 'key' components don't have to be documented; they do - they just don't control the code selection.) There should be a justifiable reason that your provider spent so much time with the patient - he just needs to explain what took so long, to be able to base his E/M code on it.
Per CMS, services, including E/M have to be medically reasonable or necessary, for a provider to bill them. He can't bump up a code to the next level on documentation elements, alone. It wouldn't be appropriate for a doctor to perform and bill a 99214, when the patient's condition warrants a lower level of service. CERT audits regularly target that kind of code selection, (especially with 99214, actually), and RAC's will downcode the claims and request a refund. And that would be the least of his troubles...
The point is, as a doctor, he's probably not wasting his time haplessly on a patient who doesn't need it; if he did a more thorough exam than what was needed to diagnose the problem, he should elaborate why he did so, in his notes. (Even a list of differntial diagnoses could suffice). The same goes for excessive counseling/CoC activities. It just has to show that they needed to do the work, and aren't trying to pad their payment, to support billing the higher code.
