EM Coding Alert

You Be The Coder:

Rely on Documentation for Test Review

Question: Our surgeon has performed an esophageal ablation of polyps for a patient in the past. At a recent appointment, the surgeon counted a review of the findings from the past procedure as part of the time for the E/M code selection, even though the surgeon previously reviewed the findings with the patient at a prior appointment. Is that OK?

South Carolina Subscriber

Answer: CPT® does not place a limit on how often a provider counts actions like the review of test results or counseling a patient about a specific issue, although different payers may possibly restrict this practice.

As a reminder, CPT® allows you to count “both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s)” toward “the total time on the date of the encounter.” Non-face-to-face time can include such activities as:

  • Preparing to see the patient (eg, review of tests).
  • Obtaining and/or reviewing separately obtain history.
  • Performing a medically appropriate exam and/or evaluation.
  • Counseling and educating the patient/family/caregiver.
  • Ordering medications, tests, or procedures.
  • Referring and communicating with other healthcare professionals (when not separately reported).
  • Documenting clinical information in the electronic or other health record.
  • Interpreting results independently (not separately reported) and communicating results to the patient/ family/caregiver.
  • Coordinating care (not separately reported).

CPT® does not allow you to count non-face-to-face activity time such as:

  • The performance of other services that are reported separately.
  • Travel.

The time as described in your question could be considered counseling and educating the patient/ family or caregiver. In this case, it would be important for the provider to document the need to revisit that information to validate the time spent.