Neurology & Pain Management Coding Alert

When time dominates the E/M encounter, the exception might apply.

If you’re not up to speed on the counseling exception rules, you could be undercoding for your provider’s service on some E/M codes. However, you may only use the exception in certain specific cases.

Help’s here: We posed a few counseling exception questions to a pair of top-notch E/M coders. Here’s what they had to say about how to use, and when to avoid using, the counseling exception when choosing E/M codes.

Use This Definition for Counseling Exception

In order to consider coding a visit using the counseling exception, you’ll need to know how providers define the coding feature.

“When the time spent during the [E/M] visit is dominated by counseling rather than performing the key components of history and examination … CPT^® permits selecting the level of E/M services based on the total face-to-face time, so long as all of the documentation supports it,” explains Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, N.M.

Specifically, if more than 50 percent of the total encounter time was spent counseling the patient, you might be able to choose an E/M code with “time as a key factor, instead of [considering] the history, physical, and MDM [medical decision-making],” explains Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Ind.

The coder must remember to check the notes for evidence that face-to-face time and counseling time are in the record. If notes indicate a possible counseling exception, the notes must include “sufficient detail regarding the counseling content to warrant selecting the E/M by time,” says Witt.

Choose Higher E/M Level With Exception … Maybe

The counseling exception is an important concept to understand because it could result in the strengthening of the practice’s bottom line when you use it correctly.

“In some cases, counseling time can lead to higher-level E/M services,” says Witt. “Some medical decision-making will be evident even for counseling-dominated visits, but a history or exam may or may not be documented as well. The physician should still document the details of the visit.”

However, it will be evident that the history, exam, or decision-making didn’t hit the mark for the level because most of the visit was spent in a counseling capacity.

Example: The physician performs a problem-focused history and straightforward MDM on a patient, which takes 10 minutes. After those services, the physician spends 17 minutes counseling the patient. This encounter took 27 minutes total, with more than half of that time (17 minutes) devoted to counseling or coordination of care. In this case, you can choose an E/M code based on encounter time rather than the history, physical and MDM components. That means you could report 99214 (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 physicians, other qualified health care professionals, 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. Typically, 25 minutes are spent face-to-face with the patient and/or family) for the encounter if the physician documents the total time, the time spent counseling, and illustrates a brief synopsis of what was discussed during the counseling.

If you did not employ the counseling exception in this instance, you would have reported 99212 (… a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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 self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family) instead (bold print added to emphasize time factor).