General Surgery Coding Alert

Lengthy but low-level E/M visits or time spent reassuring and counseling patients in the office does not have to go under-reimbursed. Often, time rather than the key E/M components of history, exam and medical decision-making (MDM) can be the determining factor when choosing an E/M service level, thereby allowing the physician to report a higher-level code than the key components would warrant alone.

According to CPT guidelines, when counseling or coordination of care dominates the physician/patient encounter (that is, comprises more than 50 percent of the visit), "time may be considered the key or controlling factor to qualify for a particular level of E/M services." Counseling and coordination and care may include discussion with the patient about one or more of the following areas: diagnostic results, impressions and/or recommended diagnostic studies, prognosis, risks and benefits of treatment options, instructions for treatment and/or follow-up, importance of compliance with chosen treatment options, risk factor reduction, and patient/family education.

For example, a patient requiring gall bladder surgery returns to the surgeon's office to gain more information about his condition. The surgeon and patient spend an hour and 15 minutes discussing the risks and benefits of surgery, other treatment options, and preventive measures to alleviate discomfort before and after surgery. The history, exam and MDM are minimal in this case, but because counseling and coordination of care dominated the encounter, you can use time as the controlling factor when assigning the E/M service level.

To determine the appropriate E/M level for the time spent with the patient, you must check the reference time included in the CPTdescriptor for each code, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. For instance, the descriptor for 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) states, "Physicians typically spend 10 minutes face-to-face with the patient and/or family," while the descriptor for 99254 (Initial inpatient consultation for a new or established patient ...) specifies, "Physician typically spend 80 minutes at the bedside and on the patient's hospital floor or unit."

Remember that to qualify as a given level of E/M service, at least half the total time (which should meet or exceed the reference time of the chosen code) must have been spent on counseling or coordination of care. Therefore, if the surgeon documents spending six minutes of a 10-minute office visit on counseling and coordination of care, report 99212. Likewise, if the physician dedicates 65 minutes of a 90-minute initial inpatient consult to counseling and coordination of care, report 99254.

Note: Time spent taking the patient's history or performing an examination does not count as counseling time. The physician must look at the entire patient encounter and decide if he or she spent the majority of time in counseling and coordination of care or if the key components of history, exam and MDM should be the deciding factor when choosing an E/M level.

Returning to the above example, you may report the 75-minute visit using 99244 (Office consultation for a new or established patient), which has a reference time of 60 minutes, as long as at least 50 percent of the visit (minus the time required to take the history and exam) involved counseling or coordination of care.

Documentation is always crucial for time-based E/M services. Most important, the physician should specifically note start and stop times for the patient visit, as well as the portion of the time spent on counseling and coordination of care, Jandroep says. CMS guidelines require that physicians document exact times, and they may have trouble during an audit if they have not noted this information.

In addition, physicians should document what issues they discussed in counseling (for example, treatment options, prognosis, etc.). For instance, the physician might note, "20 minutes with patient discussing his role in preparing for surgery, the benefits/risks of surgery, and postsurgical rehabilitation issues."

Finally, the surgeon should include the components of history, exam and MDM even if they are cursory in the documentation. Good medical record keeping requires that you document relevant and pertinent information, and using time as the determining factor to choose the E/M level does not negate this requirement.