Wiki Physician coding on time with no exam on new patient

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kapral

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I have a OB/GYN doctor that coded a new patient as a 99204 based on time, she counselled her on infertility and spent 60 minutes in the appointment, she did no exam, very little hpi, can you code solely on time without an exam at all? I know time can be an overriding factor but can you not do all 3 of 3 required?
 
time coding

Yes, you can bill on time only as long as the total amount of time spent in counseling is documented clearly in the note. I work in a fertility clinic and 99% of our e/m coding is counseling services. We use the V26.29 and V26.49 diagnosis codes and usually have no trouble getting insurance to cover the office visits.
 
When time is the controlling factor for counseling and/or coordination of care, the doctor does not need to document performance of the three key. Of course there will be some history taken, at least there usually is, as well as medical decision making, but as an auditor or coder, the key components are no longer "counted" when coding based upon time.

Here is an excerpt from Medicare Claims Processing Manual, Pub. 100-04, Ch. 12, sect. 30.6.1 C.:

"
C. Selection Of Level Of Evaluation and Management Service Based On Duration Of Coordination Of Care and/or Counseling
[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.
[/FONT][/FONT]EXAMPLE: [FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]A cancer patient has had all preliminary studies completed and a medical decision to implement chemotherapy. At an office visit the physician discusses the treatment options and subsequent lifestyle effects of treatment the patient may encounter
or is experiencing. The physician need not complete a history and physical examination in order to select the level of service. The time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.
The code selection is based on the total time of the face-to-face encounter or floor time, not just the counseling time. The medical record must be documented in sufficient detail to justify the selection of the specific code if time is the basis for selection of the code.
In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided.
In an inpatient setting, the counseling and/or coordination of care must be provided at the bedside or on the patient‟s hospital floor or unit that is associated with an individual patient. Time spent counseling the patient or coordinating the patient‟s care after the patient has left the office or the physician has left the patient‟s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported.
The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling. "

You can find this document at: https://www.cms.gov/manuals/downloads/clm104c12.pdf

The total time of the visit should be documented along with the total amount of time spent in counseling and/or coordination of care, e.g., spent 50 mins of this 60 min appt....etc....

Hope that helps!
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Kris...would this be the same for a locum tennen as well? I have been given locums to bill for from in the ER.They dont say much on the paper, but he lists the amount of time spent with the patient. Do I code an outpatient visit or consult based on time and put a Q-6 modifier on it? Your help would be greatly appreciated. Thanks...Kathy Albert,CPC
 
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