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Gastroenterology Coding Alert

READER QUESTIONS:

Sometimes You Can Up E/M Level Based on Time

Published on Sun Jun 12, 2005

Question: A patient who was diagnosed with Crohn's disease three weeks ago reports for a follow-up visit. The nonphysician practitioner took a blood test and talked to the patient about her severe anxiety, lack of sleep and depression since she was diagnosed. The visit took 26 minutes. What level E/M service should I report?


Oklahoma Subscriber
  

Answer: During E/M visits in which the NPP must provide a lot of extra counseling to a patient, you may be able to raise the E/M level based on time - if counseling and/or coordination of care dominated the encounter time and you properly document the visit.
 
On your claim, you should:
 

  •  report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity) for the office visit based on time.
     
  •  attach ICD-9 code 555.9 (Regional enteritis; unspecified site) to indicate the patient's Crohn's disease.
     
  •  attach 300.00 (Anxiety state, unspecified) to indicate the patient's anxiety.
     
  •  attach 311 (Depressive disorder, not elsewhere classified) to indicate the patient's depression.

    Documentation and diagnosis coding will be vital to this claim's success. Make sure you have a detailed description of the NPP's encounter with the patient before you send the claim.

    Your claim must reflect the reasons that you're reporting a level-four code when it appears that the NPP provided a lower-level service. Otherwise, it could be rejected.

    Best bet: Before filing this claim, make sure you can answer "Yes" to both of these questions:

    1. Does the documentation detail what the NPP discussed with the patient? There must be some record of exactly what the NPP talked about with the patient, so the payer can decide whether the NPP was counseling or coordinating care.

    2. Was the visit dominated by counseling/coordination of care time? Payers consider encounters with more than 50 percent of total time devoted to counseling and care coordination counseling-dominated.

    If you answered "No" to either of these questions, you should not raise the level of E/M service based on time. Instead of 99214, you would report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problems are minimal) for the encounter.

    Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the CPT advisory panel; and Linda Parks, MA, CPC, CCP, an independent coding consultant in Marietta, Ga.

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