Neurosurgery Coding Alert

Question: Our neurosurgeon saw a patient today for symptoms related to carpal tunnel syndrome. The patient had been to the practice before, but not for this problem. After talking with her for about 30 minutes, the surgeon discussed several non-surgical ways she should try to improve her condition before pursuing other treatment. Because he didn't examine her, how should we bill?

Texas Subscriber

Answer: Because counseling comprised more than 50 percent of the physician's time with the patient, you can base the level of service on the amount of time that the physician spent with the patient. (Remember, CPT states, "If counseling or coordination of care dominates [more than 50 percent] the physician/patient and/or family encounter, then time may be considered the key or controlling factor to qualify for a particular level of E/M service.")

For instance, if the neurosurgeon spent 30 minutes with the patient, of which he spent only 10 minutes documenting her history and test results, and he spent the remaining 20 minutes counseling her, you can legitimately bill 99214 (Office or other outpatient visit for the evaluation and management of an established patient ... physicians typically spend 25 minutes face-to-face with the patient and/or family).

The neurosurgeon must perform such a visit face-to-face (as opposed to a discussion with the patient over the phone).