EM Coding Alert

When time dominates the E/M encounter, the exception might apply.

If you’re not up to speed on the counseling exception rules, you could be undercoding for your provider’s service on some E/M codes. However, you may only use the exception in certain specific cases.

Help’s here: We posted a few counseling exception questions to a pair of top-notch E/M coders. Here’s what they had to say about how to use, and when to avoid using, the counseling exception when choosing E/M codes.

Q: What is the counseling exception, and what does it means for coders?

A: “When the time spent during the [E/M] visit is dominated by counseling rather than performing the key components of history and examination … CPT^® permits selecting the level of E/M services based on the total face-to-face time, so long as all of the documentation supports it,” explains Melanie Witt, RN, CPC, MA, an independent coding expert based out of Guadalupita, N.M.

Specifically, if more than 50 percent of the total encounter time was spent counseling the patient, you might be able to choose an E/M code with “time as a key factor, instead of [considering] the history, physical, and MDM [medical decision-making],” explains Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Ind.

The coder must remember to check the notes for evidence that face-to-face time and counseling time are in the record. If notes indicate a possible counseling exception, the notes must include “sufficient detail regarding the counseling content to warrant selecting the E/M by time,” says Witt. 

Q: What’s the benefit of using the counseling exception?

A: “In some cases, counseling time can lead to higher-level E/M services,” says Witt. “Some medical decision-making will be evident even for counseling-dominated visits, but a history or exam may or may not be documented as well. The physician should still document the details of the visit. However, it will be evident that the history, exam, or decision-making didn’t hit the mark for the level because most of the visit was spent in a counseling capacity.

Example: The physician performs a problem-focused history and straightforward MDM on a patient with asthma, which takes 10 minutes. After those services, the physician spends 17 minutes counseling the patient. This encounter was 27 minutes total, with more than half of that time (17 minutes) devoted to counseling or coordination of care. In this case, you can choose an E/M code based on encounter time rather than the history, physical and MDM components. That means you could report 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. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem[s] and the patient’s and/or family’s needs. Usually, the presenting problem[s] are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family) for the encounter (bold print added to emphasize time factor) if the physician documents the total time, the time spent counseling, and illustrates a brief synopsis of what was discussed during the counseling.

If you did not employ the counseling exception in this instance, you would have reported 99212 (… a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family) instead (bold print added to emphasize time factor).

Q: What are some other examples that might result in the counseling exception?

A:  According to Witt these might be counseling exception E/Ms, if the physician’s actions and documentation satisfy the exception requirements:

• Return visit to discuss test results.
• Educating the patient about how to monitor her blood glucose levels after her initial visit diagnosed her diabetes.
• Discussing with the patient or family (in the case of a minor) treatment options after a diagnosis of cancer.

Under the right circumstances, these encounters might also result in counseling exception E/Ms, according to Holle:

• A patient presents with a chronic condition but is non-compliant with her medication and treatment plan and the physician has to counsel on the necessity for this treatment plan.
• An elderly patient presents with chronic issues and is confused on how to take his medication.  The patient’s daughter is present and the physician counsels both of them on the correct use of medication, advice to the daughter on how to monitor medication use, etc. The patient and daughter ask questions and leave with a better understanding of the importance of a medication schedule.
• A patient arrives with his parents as he is having bed-wetting issues. After a brief history and examination to identify any physical reasons for the behavior, the physician asks further questions of the parents and they discuss options and possible treatments. The counseling around the bed-wetting takes up the majority of the visit.

Remember: These are only examples of potential counseling exception E/Ms. Each encounter is different, and you should be sure that all of the counseling exception rules are met before employing this coding technique.