Cardiology Coding Alert

Analyze Office Visits to Avoid Underpayment for Counseling

Published on Wed Jan 01, 2003

Tracking patient counseling and coordination-of-care time during an office visit can boost E/M levels and generate more reimbursement for cardiology practices.

Because cardiologists often treat chronic conditions such as coronary atherosclerosis (414.0x), they frequently take on the role of the patient's primary-care physician (PCP). Consequently, they often provide counseling and coordination of care.

According to CPT, when counseling and/or coordination of care takes up more than 50 percent of the cardiologist's face-to-face time with the patient, time becomes the determining factor when choosing a particular E/M service level. The content of the counseling and/or coordination of care what the physician talked about with the patient must be documented in the medical record, CPT states.

The AMA defines counseling as a "discussion with a patient and/or family concerning one or more of the following areas:

Diagnostic results, impressions, and/or recommended diagnostic studies

Prognosis

Risks and benefits of management (treatment) options

Instructions for management (treatment) and/or follow-up

Importance of compliance with chosen management (treatment) options

Risk factor reduction

Patient and family education."

Counseling time also includes time spent with the parties who have assumed responsibility for the patient's care or decision-making. But remember, Medicare and most insurance companies do not pay for family education without the patient present. If, for example, a family member wants to talk to a cardiologist concerning a patient's chronic systolic heart failure (428.22), Medicare requires the patient to be present in the room with the family member.

Tips for Measuring Documentation

"The physician should document the total visit time and how much of that time was spent counseling/coordinating care," says Carol Pohlig, BSN, RN, CPC, reimbursement analyst for the department of medicine at the University of Pennsylvania in Philadelphia. "The physician should also comment on the important issues discussed with the patient in addition to any relevant clinical information, such as the patient's response."

You should remember that only the physician's time spent counseling the patient can be counted toward counseling/coordination of care time. Time spent by the cardiologist's staff on the patient's case is not reportable. Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. of Lansdale, Pa., recommends the following test for compliant documentation when billing based on time:

1. Does the documentation reveal the total face-to-face time in the outpatient setting or on the unit/floor in the inpatient setting?

2. Does the documentation describe the content of the counseling or coordination of care?

3. Does the documentation reveal that the physician spent more than half of the time counseling or coordinating care?

If all of the answers are "Yes," you should specify total encounter time (in minutes), but be aware that some insurance carriers ask for specific documentation that shows the time the counseling began and ended.

Link Face-to-Face Time to Diagnoses

When counseling is part of a new patient visit, report 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient) depending on the complexity of the patient's problem and the time the patient spends with the physician. For instance, if a cardiologist sees a new 65-year-old female patient for chest pain after exertion (786.50) and spends 45 minutes face-to-face with her and spends 25 minutes of that 45 minutes counseling the patient on diet and lifestyle, you should report 99204 and link it to 786.50.

If the cardiologist counsels an established patient for a new or an ongoing problem and spends more than 50 percent of the face-to-face time counseling the patient, report the established patient office visit codes (99212-99215) based on time.

For example, a cardiologist spends 20 minutes with an established patient face-to-face and uses 12 minutes of the encounter to discuss treatment options for coronary atherosclerosis (414.0x). In this case, report 99213 (Office or outpatient visit for the evaluation and management of an established patient Physicians typically spend 15 minutes face-to-face with the patient and/or family) linked to the atherosclerosis diagnosis (414.0x).

If a nonphysician practitioner (NPP) counsels the patient, use 96150-96155, which are health and behavior assessment and intervention codes for patients who need counseling for physical health problems. These codes are in the medicine section of CPT.

For example, a 60-year-old female patient with hypertension (401.x) is having difficulty keeping her blood pressure down and sees an NPP with expertise in hypertension management. In this case, you would report one of these codes depending on the time spent with the patient, if the counseling is individual or group counseling, and whether the family was present during counseling.

Codes 96150-96155 were new in 2002, and some insurance carriers may not yet recognize them, so getting reimbursement could be difficult, coding consultants advise.

Use Risk-Reduction Codes for Problem-Prevention Counseling

If the patient sees a cardiologist just for counseling and does not have an established illness, you should use 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes), 99402 ( approximately 30 minutes), 99403 ( approximately 45 minutes) or 99404 ( approximately 60 minutes), depending on the counseling session's duration. Indeed, the preventive, risk-reduction counseling codes are not the same as those for counseling patients with established medical problems, so make sure the documentation notes are clear regarding the reason the physician is counseling the patient, coding experts warn.

Use codes 99401-99404 when the patient does not have any signs, symptoms or problems acute or chronic, stable or unstable and the counseling concerns health maintenance or prevention (in the absence of disease or injury), such as smoking cessation or exercise.

For instance, an asymptomatic patient comes to a cardiologist because he has a family history of ischemic heart disease (V17.3). The physician spends 30 minutes discussing the risks of the disease and preventive actions, such as special diets and exercise programs, which the patient can take to reduce his chances of developing heart disease. In this case, you should report 99402 linked to V17.3 (Family history of certain chronic disabling diseases, ischemic heart disease).

Typically, however, Medicare does not reimburse for 99401-99404. Some private payers do, but generally only to PCPs. If your cardiologist is not an insurer-credentialed PCP, you're not likely to receive reimbursement for the preventive counseling.