General Surgery Coding Alert

Question: Our surgeon spent time during an office visit counseling a new patient prior to breast biopsy. How should we report this?

Tennessee Subscriber

Answer: When counseling is part of a new patient visit, report 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient) depending on the complexity of the patients problem and the time the physician spends with the patient. For instance, if a surgeon sees a new 50-year-old female patient for a stomach ulcer (531.9) and spends 45 minutes face-to-face with her and spends 25 minutes of that 45 minutes counseling the patient on diet and lifestyle, you could report 99204 and link it to 531.9.

Moreover, if the surgeon counsels an established patient for a new or ongoing problem and spends more than 50 percent of the face-to-face counseling the patient, report the codes for established patient office visits (99212-99215) based on time.

If the surgeon spends 20 minutes with an established patient face-to-face and uses 12 minutes of the encounter to discuss the breast biopsy, report 99213 (Office or other outpatient visit for the evaluation and management of an established patient Physicians typically spend 15 minutes face-to-face with the patient and/or family). Link 99213 to the appropriate diagnosis code for the breast disorder, such as 611.72 for lump or mass in the breast.