Neurology & Pain Management Coding Alert

Question: I have an encounter note in front of me that I cannot decipher. Notes indicate that the physician performed an E/M service for an established patient who was just diagnosed with congenital spastic paralysis (cerebral palsy). The encounter notes only support a level-two E/M service. However, notes also indicate that the encounter lasted 30 minutes, and 18 minutes of that time were spent discussing treatment options, medication regimens, and potential medication side effects. Can I use the “counseling exception” to code a higher-level E/M in this scenario?

Texas Subscriber

Answer: As long as counseling and/or coordination of care took up at least half of the total encounter time, you should be able to use the counseling exception for this encounter. On the claim, 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…) for the E/M, with G80.0 (Spastic quadriplegic cerebral palsy) appended to represent the patient’s condition.

Explanation: Although this was a 99212 (… a problem focused history; a problem focused examination; straightforward medical decision making…) service according to the history, exam, and medical decision making key components, it is also eligible for the “counseling exception.” This exception states that when the documentation does not meet the requirements for a given level of service, and counseling constitutes more than 50 percent of the encounter, the doctor can choose an E/M code based on the face-to-face time.

Since the physician spent more than half of the 30-minute encounter discussing medically relevant treatment and care options, you can choose 99214, whose code descriptor states “Typically, 25 minutes are spent face-to-face with the patient and/or family.”