General Surgery Coding Alert

Question: Our surgeon spent 85 minutes providing a consultation for a patient in the hospital. He performed a minimal evaluation, but most of the visit was spent reviewing an MRI, discussing the results and counseling the patient. In this case, does time supersede all other elements of E/M coding? Would 99255 be appropriate?

Colorado Subscriber

Answer: CPT guidelines for 99255 (Initial inpatient consultation for a new or established patient ...) require a comprehensive history, examination and medical decision-making of high complexity. In this case, these requirements have not been met. However, a consult may be billed with time as the primary factor if counseling and coordinating of care comprise more than 50 percent of the visit (rounded to five-minute intervals). According to CPT, the physician typically spends 110 minutes with the patient for a level-five (99255) inpatient consult. Therefore, to bill this level with time as the determining factor, the physician must spend at least 55 minutes in counseling and coordination of care. This must be face-to-face time.

In this instance, the consult lasted 85 minutes. If the physician spent at least 43 of these in face-to-face counseling and coordination of care, the visit would qualify as a level-four inpatient consult (99254), which has a base time of 80 minutes.

It helps to document start and stop times for the visit. Carefully specify the time spent on counseling and coordination of care, clearly indicating that more than 50 percent of the visit was spent on these activities.

An alternative option is to report an inpatient consult at the level supported by documentation on the basis of history, exam and medical decision-making (MDM) and to bill for all time past 30 minutes using +99356 (Prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service ...; first hour [list separately in addition to code for inpatient evaluation and management service]) and +99357 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]), which describe prolonged services in the inpatient setting.

For example, the surgeon provides a consult that by the criteria of history, exam and MDM qualifies only as a level-two (99252) inpatient consult, but which involves extended discussion with the patient and therefore requires 90 minutes to complete. The surgeon may report 99252 for the consult along with 99356 for the 50 minutes of prolonged service beyond the initial 40 minutes of consult "reference time." For a 130-minute consult of the same level, report 99252, +99356, +99357 and so on.

Again, however, documentation should carefully note start and stop times to justify the time claimed toward prolonged services.