Neurology & Pain Management Coding Alert

Lengthy but low-level E/M visits or time spent reassuring and counseling patients in the office does not have to go under-reimbursed. Often, time rather than the key E/M components of history, exam and medical decision-making (MDM) can be the determining factor when choosing an E/M service level, thereby allowing the physician to report a higher-level code than would be warranted by the key components alone.

According to CPT guidelines, when counseling and/or coordination of care dominates the physician/patient encounter (meaning it comprises more than 50 percent of the visit), "time may be considered the key or controlling factor to qualify for a particular level of E/M services." Counseling and coordination and care could include discussion with the patient (or his or her family) about one or more of the following: diagnostic results, impressions and/or recommended diagnostic studies, prognosis, risks and benefits of treatment options, instructions for treatment and/or follow-up, importance of compliance with chosen treatment options, risk factor reduction, and patient/family education.

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 15 minutes discussing test results, treatment options and preventive measures to alleviate symptoms. The history, exam and MDM are minimal in this case, but because counseling and co-ordination of care dominated the encounter, time can be used as the controlling factor in assigning the E/M service level.

To determine the appropriate E/M level for a given amount of time spent with the patient, you must check the reference time included in the CPT descriptor for each code. For instance, the descriptor for 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) states, "Physicians typically spend 10 minutes face-to-face with the patient and/or family." On the other hand, the descriptor for 99254 (Initial inpatient consultation for a new or established patient ...) specifies, "Physicians typically spend 80 minutes at the bedside and on the patient's hospital floor or unit."

Recall that to qualify as a given level of E/M service, the physician must spend at least half the total time (which should meet or exceed the reference time of the chosen code) on counseling and/or coordination and care. Therefore, if the neurologist documents that she spent six minutes of a 10-minute office visit on counseling and coordination of care, you may report 99212. Likewise, if the doctor dedicates 65 minutes of a 90-minute initial inpatient consult to counseling and coordination of care, you may bill 99254.

Returning to the above example of the carpal tunnel patient, for a 75-minute visit you may report 99244 (Office consultation for a new or established patient ...), which has a reference time of 60 minutes, because at least 50 percent (that is, 38 minutes) of the visit (minus the time required to take the history and exam) involved counseling and/or coordination of care.

Documentation is crucial for time-based E/M services. Most important, the physician should specifically note start and stop times for the patient visit, as well as the portion of the time spent on counseling and coordination of care, says Barbara J. Cobuzzi, CPC, CPC-H, MBA, president of Cash Flow Solutions Inc., a Lakewood, N.J., billing company. CMS guidelines require physicians to document exact times, and neurologists may have trouble during an audit if this information is not noted.

In addition, the physician should note the issues discussed during counseling (for example, treatment options, prognosis, etc.). For instance, the physician might note, "20 minutes with patient discussing splinting, antiinflammatory medication and behavior modifications to alleviate symptoms of carpal tunnel."

Finally, the components of history, exam and MDM even if cursory should be included in the documentation. Good medical record keeping requires that you document relevant and pertinent information, and using time as the determining factor to choose the E/M level does not negate this requirement.