Neurosurgery 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 or coordination of care dominates the physician/patient encounter, i.e., 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, says Arlene Morrow, CPC, an independent coding and reimbursement specialist in Tampa, Fla.

Counseling and coordination of care may include discussion with the patient (or his or her family) about one or more of the following areas: 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, a patient with a diagnosis of spinal degeneration returns to the neurosurgeon's office to discuss a planned surgery. The surgeon and patient spend an hour and 15 minutes discussing the risks and benefits of surgery, other treatment options and preventive measures to alleviate discomfort before and after surgery. The history, exam and MDM are minimal in this case, but because counseling and coordination 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 the 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," while the descriptor for 99254 (Initial inpatient consultation for a new or established patient ...) states, "Physician typically spend 80 minutes at the bedside and on the patient's hospital floor or unit."

Remember, to qualify as a given level of E/M service, at least half the total time (which should meet or exceed the reference time of the chosen code) must have been spent on counseling or coordination of care. Therefore, if six minutes of a 10-minute office visit are documented as having been spent on counseling and coordination of care, report 99212. Likewise, if 65 minutes of a 90-minute initial inpatient consult are dedicated to counseling and coordination of care, report 99254.

Note: Time spent taking the patient's history or performing an examination do not count as counseling time. The neurologist must look at the entire patient encounter and decide if the majority of time was spent in counseling and coordination of care or if the key components of history, exam and MDM should be the deciding factor when choosing an E/M level.

Returning to the above example of the patient with spinal degeneration, the 75-minute visit may be reported using 99244 (Office consultation for a new or established patient), which has a reference time of 60 minutes, if at least 50 percent of the visit (minus the time required to take the history and exam) involved counseling or coordination of care.

Documentation is always crucial for time-based E/M services. Most important, says Barbara J. Cobuzzi, CPC, CPC-H, MBA, president of Cash Flow Solutions Inc., a Lakewood, N.J., billing company, 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. CMS guidelines require that exact times be documented, and neurologists may have trouble if their files are audited and this information is not noted.

The physician should note what issues were discussed in counseling, e.g., treatment options, prognosis, etc. For instance, the physician might note, "20 minutes with patient discussing his role in preparing for surgery, the benefits/risks of surgery, and postsurgical rehabilitation issues."

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.