General Surgery Coding Alert

Question: Can I report a physician’s discussion with an elderly patient’s caregiver about the correct way to monitor their blood pressure as professional time?

Montana Subscriber

Answer: Regarding time-based coding, your providers should include distinct time they spent with the patient providing services. The CPT^® guidelines define distinct time in the same way you’d bill based on time. Per CPT^®, professional time for a physician or other qualified healthcare professional (QHP) includes:

• “Preparing to see the patient (eg, review of tests)
• “Obtaining and/or reviewing separately obtained history
• “Performing a medically appropriate examination and/ or evaluation
• “Counseling and educating the patient/family/ caregiver
• “Ordering medications, tests, or procedures
• “Referring and communicating with other health care professionals (when not separately reported)
• “Documenting clinical information in the electronic or other health record
• “Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
• “Care coordination (not separately reported)”

The guidelines also provide direction on activities that do not count toward time spent with the patient, including:

• Performing other separately reported services
• Travel
• General teaching that isn’t limited to discussing the specific patient’s management

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC