Question: Is there any office visit code other than 99211 that a physician can use when he doesn't perform a physical examination? Our endocrinologists do not always perform a physical exam during an office visit. New patient E/M codes 99201-99205 and established patient E/M codes 99212-99215 all require a problem-focused, expanded problem-focused, detailed, or comprehensive physical exam. How should we code for a new or established patient visit without a physical exam?
New York Subscriber
Answer: In many cases, a physician may perform a history and medical decision-making but choose not to perform a physical exam. For example, a physician might opt out of the physical exam because the visit involves mostly counseling and coordination of the patient's care.
You can use time as the key factor for determining the level of service when counseling and/or coordination of the patient's care dominates (50 percent or more) the visit. Counseling may involve services such as discussion of test results and prognosis, instructions and/or education for self-care and medication, and planning for future services, to list just a few. When this is the case for a visit, you may select a new or established patient E/M code based on time.
Each of the E/M codes has a time requirement assigned to it that is listed in the CPT manual along with the other requirements for the code. For example, code 99203 for a mid-level, new patient visit has a 30-minute requirement. Therefore, to report this code based on time, a visit must consist of 15 minutes or more of counseling and/or coordination of care. In the outpatient setting, the time spent must be face-to-face time between the patient and the physician.
Important point: Your endocrinologist must document the exact time spent with the patient and what they discussed. "I spent a great deal of time with Ms. X" is not adequate documentation. Instead, the notes should say something like, "I spent 30 minutes with Ms. X discussing her treatment options, etc."
Tip: Ask your physicians to record the precise start and stop time of the visit and the exact number of minutes spent counseling and/or coordinating care - this record will help you to calculate if the visit consisted of 50 percent or more of counseling/coordination of care and to determine the appropriate-level code (for more information on coding by time, see our article "Learn the Coding Catch That Will Increase Your Level of Service" in the July 2004 Endocrinology Coding Alert).
