Neurosurgery Coding Alert

Question: Ive recently been told that I can use time as the determining factor when choosing an E/M service level. I thought that E/M levels had to be chosen according to the documented key components of history, examination and medical decision-making (MDM). Would you clarify?

Kansas Subscriber

 Answer: The three key components you mention (history, exam and MDM) are the primary considerations when choosing an appropriate E/M service level. However, CPT states, When counseling and/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 services. This provision allows for physicians to receive just compensation for lengthy, pertinent E/M visits even if the history, exam and MDM are relatively minor. The counseling or coordination of care must be face-to-face with the patient or parties who have assumed responsibility for the care of the patient or decision-making whether or not they are family members, according to CPT. You must carefully document the time component of the service to justify the E/M level you choose.
 
When counseling and/or coordination of care dominate the service, consult the reference time in the descriptor of each code within the appropriate E/M category to select the correct level of service. For example, established patient office visit 99213 has a reference time of 15 minutes (Physicians typically spend 15 minutes face-to-face with the patient and/or family, CPT states). Therefore, if during a 15-minute visit, more than 50 percent of the physicians time (about eight minutes) is spent in counseling and/or coordination of care, he or she may report 99213 regardless of the level of history, exam and MDM, as long as the medical record reflects the significance of the time component when selecting the E/M service code (of course, if the history, exam and MDM reach a level beyond 99213, you may report the higher-level service using the three key components).
 
As a second example, the surgeon meets with a patient for a consult related to an earlier injury and surgery. She performs expanded problem-focused history and exam with low MDM but spends 25 additional minutes discussing treatment options with the patient and advising him how to avoid further injury. Judging by the three components of history, exam and MDM, the visit qualifies as a level-two office consult (99242), but using time as a key deciding factor the surgeon can report the next-higher level (99243) of service. In this case, 25 minutes of a 45-minute visit (more than 50 percent of the time spent face-to-face) are spent counseling. If the surgeon documents these facts, she is justified in using time as the deciding factor in choosing an E/M level.