Anesthesia Coding Alert

Counseling and coordination of care count toward E/M time if done properly.

Believe it or not, you have a nifty tool to capture higher-level office visit codes when your pain management specialist or anesthesiologist provides mainly counseling to a patient.
If you overlook CPT's time rule, you'll end up with lower-level codes for visits involving mainly counseling and little-to-no history, examination, or medical decision making. Start benefiting from your physician's time as the controlling factor by checking out these tips.

Tip 1: Verify Note Includes 3 Items

To code based on time in an office setting, your physician must accurately document the following three items:

1: Document that more than 50 percent of the face-to-face time your physician spent with the patient is counseling and/or coordination of care, says Lisa Curtis, CPC-I, CPC-E/M, who specializes in E/M audits in the Greeley, Colo., area. "I advise my providers to state the actual time (for instance, 45 minutes was spent with the patient in total, 30 minutes in counseling)."

An auditor needs to be able to tell the percent of the visit that the physician spent on counseling and/or coordination of care, explains Patricia A. Trites, MPA, CHBC, CPC, EMS, CHCC, CHCO, CHP, CMP, CEO of Healthcare Compliance Resources in Sherman, Texas. CPT allows you to choose an office visit code based on time only when your physician spends more than 50 percent of the face-to-face time with the patient on counseling and/or coordination of care.

Take care: If documentation does not specify that your physician's encounter has met the more than 50 percent counseling requirement, you cannot use time as the controlling factor to select the level of E/M service.

2: Document a description or summary of the counseling/coordination of care including, for example, the topic, advice given, and any recommendations made.

"The physician just can't say 'Had a long discussion about X,'" Trites warns. "That won't work."

3: Document the total time spent with the patient and/or family. If you code based on time, you'll use this number to select the E/M level.

Tip 2: Go With HEM as Fallback Position

If the encounter and documentation do not support the above items, switch from using time as the controlling factor in your coding.

How: You instead have to code the visit based on the documented history, examination, and medical decision making (HEM).

Tip 3: Think 'Time' for Counseling

Any time a patient or family sees your physician for counseling, the encounter might qualify. Think of counseling for cases such as pain related to metastatic cancer or an exacerbation of chronic pain, in which your pain management specialist spends the majority of the visit explaining possible steps, surgical options, risks, and so on.

Example: An established patient presents to your office to discuss the results of a previous procedure. The physician and patient spend the full 30 minutes of a visit discussing patient's response to the diagnostic injection, available treatment options, risks, and benefits.

Solution: The history, exam, and medical decision making are minimal in this case, but because counseling and coordination of care dominate the encounter, you can use time as the controlling factor in assigning the E/M service level.

Provided the physician summarizes the counseling, you would select the E/M code based on time and report 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...), which specifies "physicians typically spend 25 minutes face-to-face with the patient and/or family."

Here's why: Going over test results, discussing surgical options, and coordinating surgery count under counseling. Counseling consists of the physician discussing with the patient and/or family one or more of several areas including diagnostic results, prognosis, risks and benefits of management (treatment) options, or importance of compliance with chosen management (treatment) options, according to the E/M services guidelines outlined in CPT.