Neurology & Pain Management Coding Alert

Question: When we bill procedures based on time, must we list the exact time spent counseling? Or can we list only the total time with a notation that the physician spent more than 50 percent of his time on counseling?

Delaware Subscriber

Answer: According to CPT guidelines, "When counseling and/or coordination of care constitute more than 50% of the physician/patient and/or family encounter, time may be considered the key or controlling factor to qualify for a particular level of E/M service." This includes time spent with those who have assumed responsibility for the patient's care or decision-making, regardless of whether they are family members (for example, a child's parents, foster parents, person acting in locum parentis or legal guardian).

When you report time associated with counseling and/or coordination of care, your physician must document two areas. First, he must include a record of the visit's total time plus the time spent in specific counseling or coordination-of-care activities. Second, he must summarize the content of his counseling in the notes.

Before you can select the appropriate E/M code (for either a new or established patient), ask yourself if counseling or coordination of care dominated the visit. If not, you-ll base the level of service on the key components (history, examination and medical decision-making).

If counseling and/or coordination of care dominated the visit, select your code based on the total time of the face-to-face encounter.

Note: Not all E/M code descriptors list typical times, which means you can't use time to select the best code. When you choose a code based on time, your physician must have spent a time closest to the code selected.

Example: Code 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) has a typical time of 15 minutes, and 99214 has a typical time of 25 minutes. If your physician's face-to-face office time is 21 minutes, select 99214 because it represents more than half of the time difference.

Bottom line: You raise an interesting question because we have official guidelines for documenting an exam, but not for time. That means coders have different opinions on how to handle the situation. Some coders, for example, say they believe the physician when he says he spent more than half his time on counseling and coordinating care. Other coders, however, want their physicians to document each detail to help justify a comprehensive exam code. Work with your physicians to set guidelines your group can consistently follow and be comfortable with in an audit.