Internal Medicine Coding Alert

Question: I have an internist who documented 60 minutes on an established patient's office visit. The internist diagnosed the patient with morbid obesity (278.01) and new onset uncontrolled type II diabetes mellitus (250.02). Since the patient was newly diagnosed and had some difficulty understanding the doctor's orders, the internist spent more than half the office visit time on counseling on therapeutic lifestyle changes and the treatment regimen. Should I code this as 99214 for the first 25 minutes and +99354 for the remaining time?

Massachusetts Subscriber

Answer: No, since counseling and/or coordination of care takes up the majority of this office visit's time (counseling represents more than 50 percent of the total time with the patient), choose the level of E/M service based on time. You would assign 99215 (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 comprehensive history; a comprehensive examination; medical decision making of high complexity ... Physicians typically spend 40 minutes face-to-face with the patient and/or family) for this office visit.

Consider this: When the internist spends more than 50 percent of an E/M service on counseling and/or coordination of care in a face-to-face encounter, select an E/M code based on the typical/average time associated with the code levels, reports the Medicare Claims Processing Manual (MCPM), chapter 12, section 30.6.15.1H. The time approximation must meet or exceed the specific CPT code you report, which is determined by the typical/average time associated with the E/M code -- you should not "round" this time to the next higher level.

Example: A physician provided a subsequent office visit that was predominantly counseling, spending 60 minutes (face-to-face) with the patient, continues the MCPM. The physician cannot code 99214, which has a typical time of 25 minutes, and one unit of code 99354. The physician must bill the highest level code in the code family (99215, which is associated with 40 minutes typical/average time units). The additional time the physician spends beyond this code is 20 minutes, which does not meet the prolonged service code +99354's "threshold" time of thirty minutes. You don't need to report a prolonged service code in this situation.