EM Coding Alert

Question: Our doctor saw a new 10-year-old patient who was recently diagnosed with diabetes. The doctor spent 90 minutes with the child and his mother discussing the diagnosis, and changes to his lifestyle and diet. Most of the doctor’s time was spent on counseling and coordination of care. Is 99205 the only E/M code that I need to report?

Colorado Subscriber

Answer: Assuming that your doctor documented the time-based service because she spent more than 50 percent of her face-to-face time on counseling or coordinating the patient’s care, you are correct to code 99205 (Office or other outpatient visit for the evaluation and management of a new patient …) for the E/M service that requires 60 minutes of face-to-face time with the patient. 

To support time-based reporting, the documentation must contain:

• The duration of the time spent on the encounter
• The time spent or percentage of the time spent on counseling and/or coordination of care (CoC)
• The reason for the counseling and/or CoC.

In this case, your physician spent 90 minutes with the patient with most of her time spent on counseling and CoC. There’s a threshold of 30 minutes before you can use a prolonged service code (99354-9957, Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; …). You add that 30 minutes to the required E/M service which brings you to 90 minutes. Because there is no extra time, you can’t use a prolonged service code for this encounter.

Take note: The face-to-face time doesn’t have to be continuous in order to use a prolonged service code but it has to be on the same day. Not all payers recognize these codes, so you will want to check with your payer prior to submission.

Pay attention: You can only report one unit of +99354 per date of service but multiple units of +99355 (…; each additional 30 minutes…) per day once you’ve reported +99354.