Gastroenterology Coding Alert

Expert tips and real-life examples can bring you clarity once and for all.

If time is money, then any GI practice that isn’t watching the clock during E/M visits could be losing cash. If you’ve ever faced confusion about how to best bill for time-based encounters, we’ve got the definitive guide today to help lead you to a solid bottom line.

Get the Background Info

As a refresher, you can bill your E/M visit based on time if “50 percent or more of the total time the physician/clinician spent providing services to the patient was in counseling or in efforts spent coordinating  care”, says Jennifer Lame, MPH, RHIT, a medical coding instructor with Southwest Wisconsin Technical College.

“The total time spent counseling the patient, coordinating care, as well as the time spent completing the key components (history, exam, medical decision making) are used as the total time for the visit,” Lame said. “The documen­tation must support the extent of time spent counseling/coordinating care,” she said.

Documentation Is in the Details

The following must be included in the medical record when coding based on time, says Pearl Evelyn Parker Hartfield, CPC, CPC-I, a coding instructor with Antonelli College and a coder with A&L Medical Coding Consulting in Hattiesburg, Mississippi:

• Total time of the visit, not just time spent counseling
• The time spent counseling/coordinating care, demonstrating that more than (>) 50 percent of the total visit time was dedicated to counseling and coordination of benefits and services
• A brief summary of counseling and coordination of care including decisions made, risks to the patient associated with treatment versus non-treatment, etc.

A reader wrote to Gastroenterology Coding Alert asking whether the following would be appropriate documen­tation for a time-based visit:

“Our physician didn’t document any exam elements for a new patient so we cannot report any CPT^® code unless we select it based on time. We know from the time stamp in his EHR that he spent 20 minutes with the patient and the notes reflect that they discussed the colitis diagnosis and possible management options. Is this appropriate for a 99202?”

In this case, the physician will probably be unable to report any code at all, since the lack of a physical exam excludes the gastroenterologist from reporting a new patient E/M code (99201-99205) and the fact that the note doesn’t say how much time was spent counseling/coordi­nating care excludes him from billing based on time.

In addition, the notation of total time spent should be in the documentation itself, not taken from a time stamp on the EHR. It’s possible that the physician began reviewing or dictating the patient’s record before even walking into the exam room with her, so the total time spent should be clearly marked and not based on the EHR’s time stamp.

Example: Saw Susan Jones today, who is a new patient with colitis. We spent from 20 minutes together, 11 minutes of which were spent talking about medication and intervention options. We also talked about possible lifestyle changes that might help improve the condition.

Check These 4 Examples of Appropriate GI-Focused Time-Based Coding Notes

If you’re just getting your feet wet with time-based E/M coding, check out these examples of documentation done right. We’ve included not only the medical record entry, but also the code that’s justified by the documentation.

Tom Smith returned to my office today to discuss his malignant colon lesion, which I excised for biopsy during his July 10 colonoscopy. We spent an hour together, about 15 minutes of which were in a brief interim history and exam, and 45 minutes of which were spent discussing test results and treatment options with him, his wife and his son. He is going to speak with an oncologist later this week. (Justified for reporting 99215).
Terri Coleman presented today to discuss her divertic­ulosis diagnosis. Spent 15 minutes of the 25-minute total visit speaking with her about the condition and answering questions about it. Reviewed other potential diagnoses and therapeutic options. Patient’s husband was also present to review and discuss therapeutic options. All questions from patient answered. Don’t see the need for routine follow-up studies unless there is a change in symptoms. Patient can return to primary care physician for monitoring and longitudinal follow-up and management of care. (Justified for reporting 99214).
During a 15-minute visit with Mr. Rowan, I spent eight minutes discussing treatment outcomes and possible problems of colitis. He also has several other conditions including diabetes and hypertension. (Justified for reporting 99213).
Mrs. Jones is a new patient presenting for severe stomach cramps. I reviewed the reports of tests performed in the hospital and spent 30 minutes of the 35-minute visit discussing nonsurgical ways she should try to improve her condition before she pursued any more serious treatment. (Justified for reporting 99203).

In this case, the total time is noted, as well as the time spent counseling, and a summary of what was discussed. Therefore, you can bill 99202 for this visit.