Gastroenterology Coding Alert

 Question: One of our gastroenterologists performed a new patient examination that initially took about 50 minutes. He was interrupted to consult on a medical emergency. Later that morning, he spent another 20 minutes completing the exam, for a total of 70 minutes. All the time was documented. The total exam time was much more than usual. Looking at the detailed history taken, the exam, and the level of medical decision-making, we determined that we could only bill a 99203. Can't we use time in this case to bill at a higher level?

                                                                                  Missouri Subscriber

      Answer: The E/M guidelines in the CPT manual state that to use time to determine a particular level of service, more than 50 percent of the time spent with the patient must be spent in counseling or coordination of care. Specifically, "When counseling and/or coordination of care dominates (more than 50 percent) the physician/ patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. 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 locum parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record."

     In your situation, the examination itself, not counseling or coordination of care, lasted about 70 minutes, so you can't use time to raise the level of service. (Had you spent this time in counseling or care coordination, you could use 99205, which suggests 60 minutes of physician time with face-to-face patient/family counseling and coordination of care.)

      However, you can use a prolonged service code, which you'll find in the Evaluation and Management section of your CPT book, if your payer reimburses for it. Use the prolonged services code in addition to any other physician services, including any level E/M code, when "a physician provides prolonged service involving direct (face-to-face) patient contact that is beyond the usual service in either the inpatient or outpatient setting." Also, these codes report the total duration of face-to-face time on a given date, "even if the time is not continuous." The total time your physician spent with this patient was 70 minutes. Based on the E/M services you provided, you would use 99203 and +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service].

      Don't be confused by the total duration times listed for these codes. When you look at 99354, for example, the total duration of prolonged services time is listed as 30-74 minutes. You don't report the first 30 minutes separately, because that time is included in the total work of the appropriate E/M code.