Medicare Compliance & Reimbursement

Question: We saw a patient who hadn't been to our practice for over a decade, and she was having multiple issues. We spent about 40 minutes talking to the patient and her daughter about how to treat her condition, and we reported 99204 for the visit. The insurer denied the claim because our documentation only supported 99203, but we have enough time spent to justify 99204. How do we prove this?

Codify Subscriber

Answer: Before using time as the controlling factor, check off the following requirements that must be documented:

1. The total time spent with the patient.

2. The time spent counseling/coordinating care, which demonstrates that more than 50 percent of the face-to-face time the physician spent with the patient/and or family was counseling/coordination of care. For instance, "Saw the patient for 40 minutes face-to-face; 25 minutes of that visit was spent in counseling."

3. A description or summary of the counseling/coordination of care provided. For instance, "Spoke with the patient and her daughter about her glaucoma diagnosis, potential treatment options and prognosis; answered multiple questions and provided them with educational information. Also discussed surgical treatment options for cataracts, as well as potential side effects from the procedure."

CPT^® lets you select an office visit code based on time only when the physician spends more than 50 percent of the face-to-face time with the patient and/or family member on counseling and/or coordination of care. If the documentation does not specify that the encounter has met the more than 50 percent counseling requirement, you cannot use time as the controlling factor to select the level of E/M service.

Therefore, if your documentation in this case did not include the above factors, you probably can't report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity ...) and will have to base your code selection on the history, exam, and medical-decision making components of the documentation.