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Gastroenterology Coding Alert

Reader Question:

Base Level of E/M on Counseling/ Coordination Time

Published on Sun Nov 25, 2012

Question: If our gastroenterologist documents: "Time spent in the evaluation of the patient with mostly medical decision making time (two thirds) is 75 min," can I choose the E/M code based on time alone?   Nevada Subscriber Answer: No, you cannot code based on time with just the documentation you have mentioned. Here's why:  You should only code an E/M service based on time alone if at least 50 percent of the visit was spent on counseling or coordination of care. The documentation of the service is best if it specifically says "counseling" or "coordinate care" and the reason that time was needed. How it works:  According to this year's CPT® manual, you can use the code closest to the documented time. "If coding by time, pick the closest typical time," said Peter Hollmann, MD, during the "E/M, Vaccines, and Time-Based Codes" session at the CPT® and RBRVS 2011 Annual Symposium in Chicago. That advice echoes previous AMA information. For instance, the August 2004  CPT® Assistant stated, "In selecting time, the physician must have spent a time closest to the code selected. For example, 99214 has a typical time of 25 minutes and 99213 has a typical time of 15 minutes. If the face-to-face office time is 21 minutes, code 99214 would be selected as it is more than half of the time difference." That means for a 35 minute visit spent on a medically necessary counseling-dominated visit, per CPT ® you could report 99215 (Office or other outpatient visit for the evaluation and management of an established patient ... Physicians typically spend 40 minutes face-to-face with the patient and/or family), since 35 minutes is closer to 40 than it is to 25, which is the typical time for 99214. Keep in mind:  CPT® notes that "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)." Remember that although the AMA, via  CPT® Assistant, directs you to code based on the "closest" time, most payers have always considered the times indicated in CPT®'s code descriptors to represent minimums or thresholds for this purpose. Under that interpretation, the physician would select the lower code (for instance 99214, Office or other outpatient visit for the evaluation and management of an established patient...physician typically spends 25 minutes face-to-face with the patient and/or family ...) unless the time was greater than or equal to the higher-level code's typical time (such as 40 minutes for 99215).

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