General Surgery Coding Alert

Many general surgeons spend a lot of time counseling patients and/or their families. For example, the treatment of a cancer patient may include a biopsy or a colonoscopy, which usually involves a lot of discussion about test results and continuing treatment options. Such discussions often take up the majority of the time spent during a visit where a very minimal examination was performed.

Although many surgeons often do not bill for such counseling, there are codes available to document time spent on such matters, which in turn can lead to substantial reimbursements.

The final paragraph on page 8 of the Evaluation & Management Guidelines of the 1999 CPT book specifically states: In the case when counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit 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. The extent of the counseling and/or coordination of care must be documented in the medical record.

In other words, if a surgeon spends more than half of his or her time going over items such as arteriograms, CT scans, MRIs or biopsy results, the normal key components for determining the level of that visit medical history, examination and medical decision-making are waived, and time becomes the key factor, allowing the surgeon to code the visit at a higher level, says Arlene Morrow, CPC, CMM, a Tampa, FL-based coding specialist. Morrow says using time as a key factor is particularly important for surgeons, who frequently need to review test results with patients and/or their families and discuss treatment options.

As an example, she cites the following informed consent scenario. A woman visits her surgeon to talk about multiple treatment options for a breast malignancy lumpectomy, mastectomy, reconstruction, radiation or chemotherapy. The surgeon spends 25 minutes with the woman, 20 of which is spent counseling.

In this scenario, without using time as the key factor, the claim might have to be filed as a 99212 (an office or other outpatient visit for the evaluation and management of an established patient where the presenting problems are minor) because little time during the visit was spent on examination, going over test results or dealing with the patients history.

But if the 20 minutes the surgeon counseled the patient is taken into account and properly documented, the claim could be filed as a 99214 (a higher level office visit) provided the visit does not fall within the global period for the biopsy.

Filing the 99214 without using time would require two out of three of the key components mentioned above, i.e., a detailed history, a detailed 12-bullet exam and/or moderate complexity of medical decision-making, which in this case did not take place.

There could be lengthy discussions about treatment options and test results, particularly if they come back abnormal, says Susan Stradley, CPC, CCS-P, a consultant in the health care division of Elliott, Davis and Company, a healthcare accounting firm in Augusta, GA.

And, by documenting the time spent counseling the patient, Stradley adds, the resulting reimbursement could be twice that of the 99212 (which is what you would bill if time were not considered).

Documentation is Critical

Documenting the time expended counseling patients is a legitimate way for surgeons to optimize their reimbursement when they spend a lot of time in cognitive services, rather than hands-on exams, says Rita Scichilone, MHSA, CCS-P, a manager in the coding products and services division of the American Health Information Management Association (AHIMA).

But in order to successfully file a 99214 using time as the main factor, the documentation must be complete. It is not enough simply to document that counseling took place and the amount of time spent; rather, the claim must include a concise description of the content of the counseling, the names of the family or others present, as well as descriptions of brochures or handouts given.

In other words, the nature of the discussion and the amount of time spent needs to be carefully noted, although descriptions of the counseling given can be offered in general terms.

Note: Only time spent counseling face-to-face is counted. Counseling time does not include the surgeons examination of test results away from patients.