Internal Medicine Coding Alert

Published on Thu Nov 17, 2011 PDF

Question: Our physician spends lot of time discussing treatment options, imaging results, and other issues with patients. How should she document these activities to support coding E/M based on time?

Arizona Subscriber

Answer: When counseling and/or coordination of care take up more than 50 percent of the encounter, and you choose to code based on time, CPT®'s E/M guidelines state, "the extent of counseling and/or coordination of care must be documented in the medical record." Medicare's 1995 and 1997 E/M documentation guidelines add that the physician should document the total length of the encounter and "describe the counseling and/or activities to coordinate care."

In the office or outpatient setting, you should count face-to-face time. In the hospital or in a nursing facility, you can count floor/unit time, according to both CPT® guidelines and Medicare's documentation guidelines. CPT® guidelines describe the encounter as a "physician/patient and/or family encounter."

Example: The physician might document spending 20 minutes of a 25-minute encounter with an established patient discussing test results and going over the likely outcome of a procedure (she should be specific when documenting the test results). The physician fills in the remaining details of the visit, as appropriate. In this case, based on the 25-minute session, you could report 99214 because the code specifies the visit usually lasts 25 minutes. The full descriptor reads: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.