Anesthesia Coding Alert

Question: Our physicians sometimes spend a lot of time counseling and explaining treatment options to pain patients. What is the best way to submit for these E/M visits?

Mississippi Subscriber

Answer: Although CMS documentation guidelines state that history, examination and medical decision-making are the key components in selecting the E/M services level, the descriptors for the levels of E/M services also include four additional components: counseling, coordination of care, nature of presenting problem, and time. The time component is of particular relevance to pain management practitioners.

CPT code definitions for many E/M services include the amount of time the physician typically spends with a patient. For example, E/M code 99214 (Office visit, established patient, level four) states that the physician typically spends 25 minutes face-to-face with the patient and/or family. When a physician spends more than 50 percent of the E/M visit counseling a patient, time is the key or controlling factor in qualifying for a particular level of E/M service. This exception is pertinent to pain management providers who may spend extra time talking with a patient about his or her treatment, including counseling on the benefits of exercise and proper nutrition.

But if a doctor submits a number of E/M services to Medicare or private payers based primarily on time, these claims can raise a "red flag" with the carriers. Physicians should carefully record what they discussed with the patient during the visit and base the E/M service level on time only when they can justify it through medical necessity and documentation.