Anesthesia Coding Alert

 Question: I'm new to pain management coding, and am learning how to use the different E/M service codes. When might I use the higher-level codes for my specialist?

Texas Subscriber

 Answer: You'll probably report most of your specialist's E/M services with codes that end with 1 or 2, such as 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making). Occasionally, however, his work might merit a higher-level code. 

 Example 1: Another physician refers a patient with pancreatic cancer to your specialist for his opinion on pain management. Your physician completes a full examination and reviews the patient's records, x-rays, operative reports and other documentation. He spends 35 minutes examining the patient and 20 minutes counseling, for a total time of 55 minutes.

 You could report a level-four code such as 99204 (... a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity) for the visit. CPT notes that "Physicians typically spend 45 minutes face-to-face with the patient and/or his family" when you report 99204.

 Example 2: Your physician sees a patient under the same circumstances but spends 75 minutes on the examination, review and counseling. He doesn't note the amount of time spent on the physical exam versus the other components, but he does complete a comprehensive exam. You can report a level-five code such as 99205 (... a comprehensive history, a comprehensive examination, and medical decision-making of high complexity) for his service. The physician typically spends 60 minutes face-to-face with the patient and/or family when you submit 99205.