Ob-Gyn Coding Alert

Get the Payment You Deserve for Extra Time Spent With Patients Tracking patient counseling and coordination of care time during an office visit can boost E/M levels and, therefore, mean more reimbursement to your ob/gyn practice. Because ob/gyns usually see patients on a regular basis, they frequently take on the role as a woman's primary-care physician (PCP). Consequently, they often provide counseling and coordination of care. According to CPT, when counseling and/or coordination of care takes up more than 50 percent of the ob/gyn's face-to-face time with the patient, you may consider time the controlling factor to qualify for a particular E/M service level. The extent of counseling and/or coordination of care must be documented in the medical record, CPT states. The AMA defines counseling as a "discussion with a patient and/or family concerning one or more of the following areas: Diagnostic results, impressions, and/or recommended diagnostic studies Prognosis Risks and benefits of management (treatment) options Instructions for management (treatment) and/or follow-up Importance of compliance with chosen management (treatment) options Risk factor reduction Patient and family education." Counseling time also includes time spent with the parties who have assumed responsibility for the patient's care or decision-making. But remember, Medicare and most third-party payers do not pay for family education without the patient present. For example, if a family member wants to talk to the ob/gyn concerning home care of the patient's endometrial cancer (182.0, Malignant neoplasm of body of uterus; corpus uteri, except isthmus [includes the cornu, fundus, endometrium and myometrium], or 182.1, Malignant neoplasm of body of uterus; isthmus [lower segment of the uterus]), Medicare requires the patient to be present in the room with the family member. How to Document Time "The physician should document the total visit time and how much of that time was spent counseling/coordinating care," says Carol Pohlig, BSN, RN, CPC, reimbursement analyst for the department of medicine at the University of Pennsylvania in Philadelphia. "The physician should also comment on the important issues discussed with the patient in addition to any relevant clinical information (e.g., patient response)."

You should remember that only the physicians time spent counseling the patient can be counted toward counseling/coordination of care time. Time spent by the ob/gyns staff on the patients case is not reportable. And the code you choose will depend on the counselings nature. For example, if the counseling relates to a problem such as unresolved abdominal pain (789.0x) or viral warts (078.10), you should choose a level of service based on time from the outpatient E/M visit codes (99201-99215). For instance, the ob/gyn spends 20 minutes with an established patient discussing treatment options for her viral warts, which were diagnosed during a previous visit. The [...]