General Surgery Coding Alert

Question: May I report 90846 if a physician meets with a patient's family to discuss treatment options, care, questions regarding the patient, etc.?

North Carolina Subscriber Answer: No, you may not report 90846 (Family psychotherapy [without the patient present]) for such services. This code is specific to psychiatric services (and, therefore, accepted by most payers only when reported by a trained psychologist) and does not properly describe time the surgeon spends discussing the patient's condition personally with the patient or his family.
 
Rather, you may choose from either the new patient (99201-99205) or established patient (99211-99215) E/M codes, as appropriate. According to CPT, if counseling and/or coordination of care consumes more than 50 percent of the physician's time spent face-to-face with the patient or family, you may consider time as the controlling factor to qualify for a particular level of E/M service. This can include time spent with parties who have assumed responsibility for the patient care or decision-making whether they are family members or not.
 
For example, the physician spends 30 minutes counseling an established patient's family regarding proper care for a patient with a disabling neurological condition. Consulting CPT, you will note that the reference time for 99214 is 25 minutes. In this case, the physician has spent the entire 25-minute visit in counseling. You are justified in choosing 99214 as long as the physician has properly documented this time.
 
If the physician first meets the patient for a 15-minute examination, then calls in the family for an additional 30 minutes of counseling, you may report 99215 regardless of the level of history, exam and medical decision-making. In this case, the visit lasted 45 minutes (the reference time for 99215 is 40 minutes), and the physician spent the majority of the visit providing counseling and coordination of care. Therefore, time is the deciding factor.
 
Remember: The physician must document the extent of counseling and/or co-ordination of care in the medical record. He must note the start and stop times for the visit, the total amount of time he spent in counseling and/or coordination of care, as well as the issues he discussed. In this way, you demonstrate to the payer that time was indeed the deciding factor in choosing the E/M level reported.