General Surgery Coding Alert

Question: Our surgeon has performed an esophageal ablation of polyps for a patient in the past. At a recent appointment, the surgeon counted a review of the findings from the past procedure as part of the time for the evaluation and management (E/M) code selection, even though the surgeon previously reviewed the findings with the patient at a prior appointment. Is that ok?

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Answer: CPT^® does not place a limit on how often a provider counts actions like the review of test results or counseling a patient about a specific issue, although different payers may possibly restrict this practice.

As a reminder, CPT^® allows you to count “both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s)” toward “the total time on the date of the encounter.” Non-face-to-face time can include such activities as:

• Preparing to see the patient (eg, review of tests).
• Obtaining and/or reviewing separately obtain history.
• Performing a medically appropriate exam and/or evaluation.
• Counseling and educating the patient/family/caregiver.
• Ordering medications, tests, or procedures.
• Referring and communicating with other healthcare professionals (when not separately reported).
• Documenting clinical information in the electronic or other health record.
• Interpreting results independently (not separately reported) and communicating results to the patient/ family/caregiver.
• Coordinating care (not separately reported).

CPT^® does not allow you to count non-face-to-face activity time such as:

• The performance of other services that are reported separately
• Travel

The time as described in your question could be considered counseling and educating the patient/ family or caregiver. In this case, it would be important for the provider to document the need to revisit that information to validate the time spent.