Medicare Compliance & Reimbursement

Here's when you can code past the three E/M component levels.

The physician provides an evaluation and management service for an established patient that requires an expanded problem focused history and exam. The E/M encounter, however, takes nearly 45 minutes to complete. How would you report this E/M service?

Opportunity: If the visit meets the correct counseling/coordination of care parameters, you might be able to report the visit using time as the controlling factor rather than the standard three key components.

Check out this FAQ on when to invoke to the counseling/coordination of care rule and when to choose the E/M level based on traditional means.

Coders can choose an E/M code based on time "when counseling is more than 50 percent of the encounter," explains Kathleen Goodwin, CPC, coding coordinator with La Porte Regional Health Systems in Indiana.

Remember: "This is assuming the documentation notes the total time of the encounter, and that counseling dominated the encounter and the content of the discussion," continues Goodwin. By "domination," CPT means that at least half of the session time went toward counseling and care coordination, confirms Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting, Inc. in Lansdale, Penn.

"AMA Documentation Guidelines state that where counseling and/or coordination of care dominates the physician/patient family encounter, time is considered the key or controlling factor to qualify for a particular level of E/M services," she relays.

The counseling/coordination of care time must be face-to-face time in the office or other outpatient setting, or floor/unit time in the hospital or nursing facility, warns Falbo.

In a nutshell: Consider the example in the opening paragraph. Notes indicate that the doctor provides an office E/M consistent with level-three service, based on the history and exam. Total encounter time is 45 minutes, however, and 25 of those minutes were spent counseling the patient and coordinating care. In this instance, you would be able to report 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 the service.

In a physician practice, there are a number of scenarios in which counseling/coordination of care might dominate a session, says Tina Landskroener, CPC, CCS-P, PCS, business office manager for Blessing Physician Services in Quincy, Ill. "Sometimes, it's just common humanity" that prompts a counseling coding opportunity, she explains. As long as the counseling time focuses on the primary diagnosis, you should be able to code based on time.

"If a patient just learned of a malignancy, you've got the cancer itself and the lifestyle changes that you have to discuss with him. Plus, the patient just learned he has cancer; so counseling is pertinent to the diagnosis," Landskroener says.

Here are a few other types of encounters that might be eligible for coding based on time, according to Goodwin:

• Patient returns to have lab results read and learns she has diabetes. The doctor has to educate the patient about the overall management of the disease, diet, exercise, etc.

• Parents of a child with attention deficit hyperactivity disorder (ADHD) discuss different management options for home and school with the physician.

Example: An established patient is scheduled to have a cardiac catheter procedure related to his unspecified heart valve anomaly. The patient is understandably nervous and has several questions for the doctor. Over the next 27 minutes, the physician explains to the patient the consequences of not having the procedure. She also explains exactly what will take place, length of recovery time, and possible side effects. Notes indicate a level three E/M service based on the three key components, but the doctor spent 46 total minutes face-to-face with the patient.

In this instance, you should code based on time rather than the standard E/M components. On the claim, report the following:

• 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 the E/M.

• 746.9 (Other congenital anomalies of heart; unspecified anomaly of heart) appended to 99215 to represent the patient's condition.

Consider the above example. If you had reported 99213 (...an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ... Physicians typically spend 15 minutes face-to-face with the patient and/or family) instead of 99215, you would have received about half the money for the same service.

Payouts: The average reimbursement for 99213 is approximately $66, whereas for 99215, you'll net about $133.