Internal Medicine Coding Alert

Question: If an established patient presents with a rash but most of the time is spent counseling for Alzheimer's, which code should I use?

California Subscriber 

Answer: Basically there are only a few situations where time counts in the E/M arena, and it requires that 50 percent of a visit involve counseling and/or coordination of care. This includes face-to-face time in the office with the patient, the family and/or the guardian or time spent coordinating care on the hospital or nursing room floor. Keep in mind that counseling in the E/M context is not psychotherapy. 

Psychotherapy has its own time-based codes (90804-90857) for use when physicians provide psychotherapeutic counseling to patients with depression or other psychiatric disorders. Counseling as part of an E/M service is defined as a discussion with the patient, family and/or guardian about the risks and benefits of a contemplated therapy, diagnostic results or recommended tests, patient prognosis, risk-factor reduction or other aspects of patient education.

For example, the elderly patient with Alzheimer's disease who presents for an office visit accompanied by her daughter could be a patient the physician has known for years. Perhaps only five minutes may be needed to review the history, perform an appropriate exam and discuss medications. But another 20 minutes may be required to discuss with the daughter the care needed at home, the availability of community resources or coping skills. That time factor could change the visit from a 99212 or 99213 to a 99214. The physician would document the total time spent with the patient as 25 minutes, 20 minutes of which were spent counseling the patient and the family on prognosis and treatment options.

According to the CPT manual, counseling and/or coordination of care with other providers or agencies consistent with the nature of the problem(s) are self-limited or minor. Code 99212 accounts for 10 minutes of face-to-face time with the patient and/or family, 99213 for 15 minutes, 99214 for 25 minutes, and 99215 for 40 minutes.