EM Coding Alert

Question: My physician saw a patient for arthritis. Although the patient has been to our practice before, he had never visited for this particular problem. After talking with him for about half an hour, the physician discussed several nonsurgical ways he could improve his condition (changes in diet, lifestyle, exercise, etc.) before pursuing a more serious treatment. How should we bill for this visit?

South Carolina Subscriber

Answer: When counseling and/or coordination of care dominates (more than 50 percent) of the physician’s time with the patient and/or family, you can base the level of the evaluation and management (E/M) service on the amount of time the physician spent with the patient, according to the 2017 CPT^® manual.

Example: The physician spends 30 minutes with the patient. He spends 10 of the 30minutes documenting her history and test results, and he spends the remaining 20 minutes counseling her. In this case, you can legitimately bill 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity … Typically, 25 minutes are spent face-to-face with the patient and/or family) for the service.

Note: According to the 2017 CPT^® manual, this includes “time spent with parties who have assumed responsibility for the care of the patient or decision-making whether or not they are family members (e.g., foster parents, person acting in loco parentis, legal guardian).”

Don’t forget: The physician must perform a visit such as this face-to-face, as opposed to a discussion with the patient over the phone. And, as always, the physician must document the extent of counseling and/or coordination of care in the medical record. Additionally, a new problem doesn’t make the patient new again if he’s been seen in the last three years.