Neurology & Pain Management Coding Alert

Proper documentation of time spent  can increase your level of service

You may be settling for less money than you deserve if you don't code by time for your neurologist's counseling services.

Little-known fact: You can code an E/M service based on time when the physician spends more than 50 percent of his face-to-face time with the patient providing counseling and/or coordinating care.
 
CPT states if counseling and/or coordination of care constitutes more than 50 percent of the physician/patient encounter, you may use time as "the key controlling factor to qualify for a particular level of E/M services." CPT also stresses that to code by time the physician must clearly document the extent of counseling and the time involved.

The basics: For most E/M codes, CPT lists the time the physician usually spends rendering the service. For example, for established patient code 99214, CPT states, "Physicians typically spend 25 minutes face-to-face with the patient and/or family." This is called the "reference time."
 
How to use the reference time: Suppose your physician only completes an expanded problem-focused history and examination on an established patient (enough for a level-three visit), but spends a total of 25 minutes with the patient and documents that he spent 18 of those minutes providing counseling. Because more than 50 percent of the visit consists of counseling, you can use the total time to determine the level of service. In this case, you could report 99214 - which pays about $35 more than 99213.

Document and Verity All Times Involved

The most important part of coding by time is having complete and adequate documentation of the visit - including documentation of the total visit time and the total time the physician spends counseling, says Lynn M. Anderanin, CPC, director of coding and appeals at Healthcare Information Services in Des Plaines, Ill.

If you want to be able to code based on time, make sure your physicians know to document the following:

1. Beginning and end time of the counseling and/or coordination of care. This information is crucial for determining if the counseling accounted for more than 50 percent of the visit.

2. Beginning and end time of the overall face-to-face visit. "I've actually gotten some of my physicians in the habit of writing the time they go into a room and writing the time they step out of the room - and that often helps us prove that 50 percent of the visit or more was spent on counseling," says Jaime Darling, CPC, with Graybill Medical Group in Escondido, Calif.

3. Details about the counseling session's content. Auditors will consider a claim fraudulent if you coded by time but your physician only documented "spent time counseling." The physician must at least provide a summary of what the counseling or coordination of care involved, Darling says.

Counseling may involve services such as discussion of test results and prognosis, instructions and/or education for self-care or medication, and planning for future services, says Judy Richardson, MSA, RN, CCS-P, senior consultant with Hill & Associates in Wilmington, N.C.

Next, calculate: If your physician provides all the necessary time documentation, you then need to calculate the total visit minutes and total counseling minutes to prove that counseling dominated the visit.

Play it safe: If your physician does not include enough information about the patient's visit, you may have no choice but to code a lower-level service.

Be careful what you count as "counseling": Time spent taking the patient's history or performing an examination does not count as counseling time.

Take Advantage of 2 Main Benefits

CPT's code-by-time catch may allow you to justify a higher-level E/M code, or to report a visit that lacks one of the required key components (history, exam and medical decision-making, or MDM) if counseling dominates the visit, Darling says.
 
1. Higher level of service: For example, an established consult patient with a chief complaint of carpal tunnel syndrome (354.0) returns to the neurologist's office to discuss the results of previously administered diagnostic tests. The neurologist and patient spend an hour and 25 minutes discussing test results, treatment options and preventive measures to alleviate symptoms.

The history, exam and MDM are minimal, but because counseling and coordination of care dominated the encounter, you can use time as the controlling factor when assigning the E/M level.

In this case you may report 99245 (Office consultation for a new or established patient ...), which has a reference time of 80 minutes, for the 85-minute visit because at least 50 percent of the visit involved counseling and/or co-ordination of care.

2. Visit lacking one required key component: Physicians often spend time-consuming visits coordinating care for patients, but they don't always document an adequate history or exam. Even if one or more of the required components is completely missing from the visit, the CPT guidelines indicate "you can still code for the visit based on time as long as the physician spends 50 percent or more of his time counseling the patient," Darling says.

For example, the neurologist meets with an established patient to review the results of a recent polysomnography. The neurologist takes a minor history but performs no physical exam. The documentation indicates a 45-minute total visit time, and the physician devotes 35 of those minutes to coordinating the patient's plan of care. If you code by time for the visit, it qualifies for a level-four patient visit - 99214.