Wiki Selecting E/M level based on time

medicalauditor

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Hi guys,
I have a question about selecting an E/M level based on time when counseling and/or coordination of care dominates (greater than 50% of face-to-face time) the encounter. I know and understand the documentation requirements for this, however, my question is - Does choosing an E/M code based on time mean that the encounter does not need to have the 3 key elements of history, exam and MDM? My understanding is that every E/M visit still needs to have history, exam and MDM to qualify as an E/M service, but that the LEVEL of the E/M code can be based on the counseling time. Am I right? If so, can anyone guide me to a CMS resource or some other credible resource that states this? Thanks so much.
 
You can bill E/M on EITHER hx, exam and medical decision making OR time if >50% counseling/coordination of care.
See top of page 7, and bottom of page 20.
Well, I know that you can select the LEVEL of E/M based on time and that's what the guidelines say - "Visits that consist predominately of counseling and/or coordination of care are an exception to this rule. For these visits, time is the key or controlling factor to qualify for a particular level of E/M services." My question is about the whole encounter not qualifying as an E/M if there is no history, exam and medical decision making. For example, a physician sees a patient for knee pain. The history is EPF, exam is EPF and MDM is of low complexity. This would make it a 99213, however, he spends 30 minutes with the patient, of which more than 50% time is spent in counseling. So based on the time, he can bill 99214. So in this example, there IS a history, exam and MDM, but the code is selected based on time. BUT what if the provider does not document any history, exam or MDM, there is no assessment or plan or anything in the chart note at all, and he just documents that patient was called in to educate him about the opioid epidemic in the US and he bills 99215 because he talked to the patient for 45 minutes. He claims that this is counseling and he should be able to bill 99215 (its a different matter altogether that making a purely educational presentation does not qualify as counseling, but for the sake of argument, lets say it is considered as counseling.) Can he bill 99215 just because he talked to the patient when there was no history, exam, or medical decision making involved?
 
Every E/M does not require hx, exam and MDM. For example, there are some specialties (palliative care follow up comes to mind), where the physician may not perform an exam, or again go over history, but spends 45 minutes co-ordinating other specialties, discussing management, family meeting input.
In your original post, I interpreted that 1 or 2 of hx, exam & MDM were there. That is certainly a head scratcher for me if NONE are there. I've been doing this for almost 25 years, and never saw that.

Instead, I'll go back to the overarching criterion of medical necessity. Why would the provider need to talk to a patient for 45 minutes about the opioid epidemic with no mention of history, exam or MDM? I could understand if the pt presented for chronic back pain, and the physician was prescribing meds, and was concerned about this specific patient due to hx, etc. Overall, this just seems suspicious for a visit at all, let alone 99215. I would say if the entire note just states something like "spent 45 minutes face to face with patient discussing opioid epidemic", that is not an E/M.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r178cp.pdf from the CMS claims processing manual discusses medical necessity stating "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported." Further down, they discuss E/M billing based on time, and state "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." I say this was not a billable visit, unless there was medical necessity to discuss the issue with the patient.
 
Every E/M does not require hx, exam and MDM. For example, there are some specialties (palliative care follow up comes to mind), where the physician may not perform an exam, or again go over history, but spends 45 minutes co-ordinating other specialties, discussing management, family meeting input.
In your original post, I interpreted that 1 or 2 of hx, exam & MDM were there. That is certainly a head scratcher for me if NONE are there. I've been doing this for almost 25 years, and never saw that.

Instead, I'll go back to the overarching criterion of medical necessity. Why would the provider need to talk to a patient for 45 minutes about the opioid epidemic with no mention of history, exam or MDM? I could understand if the pt presented for chronic back pain, and the physician was prescribing meds, and was concerned about this specific patient due to hx, etc. Overall, this just seems suspicious for a visit at all, let alone 99215. I would say if the entire note just states something like "spent 45 minutes face to face with patient discussing opioid epidemic", that is not an E/M.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r178cp.pdf from the CMS claims processing manual discusses medical necessity stating "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported." Further down, they discuss E/M billing based on time, and state "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." I say this was not a billable visit, unless there was medical necessity to discuss the issue with the patient.
I agree, I did conclude that these visits are not E/M at all, let alone 99215. The reason for the discussion, is that this provider is calling patients in for group classroom presentations about purely educational topics, like "the role that love can play, in helping with chronic pain", "fundamentals of opioids" etc. - at the end of the narrative, he states that 45 minutes or an hour was spent face-to-face with the patient. In some cases, the classroom presentation is within 1 day of an office visit when a comprehensive history, exam and MDM were done, so there would be no medical necessity to perform any of these again the next day, just for a classroom presentation. I know that you can bill 99078 for group visits, but I am arguing that he can't even bill 99078 for these visits, because the topics of the classroom sessions are very general, they are purely informative/educational & there is no medical management in these visits. One of the topics is also the role that sunshine plays and the role that enjoyment plays in helping with pain. Like you said and I have mentioned in my audit findings, medical necessity is the overarching criterion for payment and I don't think these services are medically necessary. On top of that, to bill 99215 for each patient in the group, is definitely potential fraud, in my opinion. Thanks so much for the link, I do have resources about E/M billing based on time, but I did not see one that said "the physician may document time spent with the patient in conjunction with the medical decision-making" - This will help a lot :). One more thing, do you know where I could find more information about 99078 in terms of what kind of topics and discussions are allowed? If I could substantiate my opinion further about these visits not qualifying for 99078, it would help. The code description just says "educational services rendered to patients in a group setting" eg. prenatal, obesity or diabetic instructions, but has no more guidelines on what kind of educational services are covered, other than the examples given. I know Medicare does not cover 99078, but medicaid does, with some diagnoses. Once again, thanks for your time and help.
 
I have no personal experience using 99078. But it seems the intention of the code is for medical education. So, some topics would be clear cut yes (like diabetes education) and others would be clear cut no (like how to backyard garden). And a lot would fall into a gray area, and likely require a medical diagnosis related to the education provided. My brief search also seems to indicate many insurances will not cover this code. Does the provider plan on charging the patients who would not be covered by insurance for this? If not, then I don't think you can bill the insurance patients.
From what I've seen, practices and health systems that do offer educational seminars typically either:
1) charge all attendees a flat rate
2) provide free of charge, as a service for their patients
 
I have no personal experience using 99078. But it seems the intention of the code is for medical education. So, some topics would be clear cut yes (like diabetes education) and others would be clear cut no (like how to backyard garden). And a lot would fall into a gray area, and likely require a medical diagnosis related to the education provided. My brief search also seems to indicate many insurances will not cover this code. Does the provider plan on charging the patients who would not be covered by insurance for this? If not, then I don't think you can bill the insurance patients.
From what I've seen, practices and health systems that do offer educational seminars typically either:
1) charge all attendees a flat rate
2) provide free of charge, as a service for their patients
Thanks. Not sure what the provider does with patients that don't have insurance. For the ones that do, he is billing 99215 for each patient in the group. I will keep looking for more info on 99078 just so I can substantiate my opinion that he can't even bill 99078 for these services. Thanks a lot again :)
 
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