Ob-Gyn Coding Alert

Key: Don’t rely on ‘I spent more than an hour with the patient’ provider comments.

If you are coding office visits based on the time your ob-gyn is spending with a patient, make sure he is documenting three key elements – and we aren’t talking about history, exam, and medical decision making. Otherwise, you’ll face payer take-backs, or worse.

Even if your physician says that he spent over an hour with a patient, you can’t automatically report 99215 (Office or other outpatient visit for the evaluation and management of an established patient … typically, 40 minutes are spent face-to-face with the patient and/or family). Medical record auditors hear it nearly every day from practitioners: “You can’t downcode my claim! I spent an hour with that patient, so I know I deserve a 99215.” Unfortunately, your ob-gyn’s memory won’t hold up in court – only complete documentation will do so.

Get It In Writing

Background: When medical auditors review E/M claims, they typically code the reports based on history, exam, and medical decision-making, unless the physician meets the criteria to code a claim based on time spent with the patient. However, full-time auditors will tell you that they hear from physicians at least once a day who argue that, although their documentation may not support 99214s and 99215s, the codes are justified based on the fact that the patient had many questions and counseling took up an hour of their time.

Myth: Your ob-gyn’s argument that he spent a significant amount of time counseling the patient justifies high-level codes.

Reality: The physician’s memory may be pristine, but it can’t be relied upon if the payer asks for a refund due to insufficient documentation. Instead, your ob-gyn must note the content of the conversation with the patient in the record as well as the time spent.

Coding for a provider’s services must be based exclusively on the documentation of the service, experts say. Therefore, it is imperative that the documentation accurately portrays the services provided not only for coding compliance but also malpractice risk management. Payer reviews often do not occur within a week of services. It is difficult for providers to remember the specifics of a patient visit a week ago, let alone a month ago, a year ago or even several years ago.

Test Your Know-How

See if you can spot the problem with this chart entry:

A 72-year-old patient seen for overactive bladder (chief complaint) follow-up visit. She has been on medication (HPI-modifying factor) for one month (HPI-duration) but is not doing well and has an acute UTI as well (HPI-quality), as determined by a urinalysis (HPI-context). She is still having problems with moderate pain during urination and frequency (HPI-severity, associated signs and symptoms). The patient previously had a hysterectomy (past history). She has also noted problems with appetite (ROS-constitutional) and sleep issues (ROS-neurological). Physical examination consists of a brief constitutional examination (can’t give credit here as there are no details). Extensive counseling is done, discussing additional ways she can try to decrease her symptoms, and also to talk about pelvic floor muscle therapy, biofeedback, and Botox bladder injections (counseling description). The ob-gyn prescribes an antibiotic for the UTI and schedules bladder injections (prescription drug management-table of risk-moderate) (MDM risk: 2 pts) and a follow-up appointment is planned in one month. Total face-to-face time is 25 minutes.

Did you spot it? The problem with this record is that you can’t use the 25 minutes of time spent without knowing how much of that time was spent counseling.

Include 3 Items in Documentation

Before using time as the controlling factor, check off the following requirements that must be documented:

• the total time spent with the patient
• that more than 50 percent of the face-to-face time the physician spent with the patient/and or family is counseling/coordination of care. For instance, “Saw the patient for 25 minutes face-to-face; 20 minutes of that visit was spent in counseling.”
• a description or summary of the counseling/coordination of care provided. For the example above, you could consider, “Done to address coping strategies for the patient’s diagnosis of overactive bladder and treatment options.”

Official word: The Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.C states: “The code selection is based on the total time of the face-to-face encounter or floor time, not just the counseling time. The medical record must be documented in sufficient detail to justify the selection of the specific code if time is the basis for selection of the code,” points out Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Mich.

“Provider documentation such as ‘I had a lengthy discussion...’ or ‘I spent a great deal of time with the patient discussing...’ does not support using the dominant counseling/coordination of care as the basis for level of E/M service,” experts warn.

You should only select an office visit code based on time when your ob-gyn spends more than 50 percent of the face-to-face time with the patient and/or family member on counseling and/or coordination of care.

Avoid templated documentation: While you want to encourage your ob-gyn to document the time criteria when time-based billing is most appropriate, you don’t want your provider to go too far in the opposite direction. “Providers that include a templated statement in all of their documentation such as ‘I spent greater than 50% of the ___ visit counseling the patient’ in which they routinely fill in the blank with the time required for a level 4 or level 5 service, risk repercussions during a payer review, experts say. The documentation does not provide the required detail regarding what the provider counseled the patient on.

Key: Medical necessity must also be a key factor in your code choice. Be sure that the time spent with the patient is warranted, Young warns. “Just because the patient and provider talked for a long time doesn’t mean it was medically necessary to do so,” she says.

Know Your Payer’s Rules

The CPT^® codes that can be billed based on time, such as new and established office visit codes, contain a time within their code descriptor. For example, level-five new patient code 99205 states “Typically, 60 minutes are spent face-to-face with the patient and/or family.” Some payers consider this time a minimum time that must be met and others consider it a general estimate and allow you to round up or require you to round down to the closest specified time.

Example: There is a difference between CPT^® and Medicare regarding how to determine the level of E/M service using the total service time, experts say. CPT^® has published in the CPT^® Assistant: “In selecting time, the physician must have spent a time closest to the code selected’ whereas Chapter 12 of the Medicare Claims Processing Manual states ‘The time approximation must meet or exceed the specific CPT^® code billed (determined by the typical/average time associated with the evaluation and management code) and should not be ‘rounded’ to the next higher level.’”

Use Elements When Time is Unknown

If your ob-gyn does not document the three elements necessary for time-based code selection, you must look at the history, exam, and medical decision making. When the documentation does not support using time spent in counseling and/or coordination of care, the level of service must be determined on the documentation of the three key components solely, experts say.

In the example above, because the time spent in counseling/coordinating care is unknown, you instead have to code the visit based on the documented history, exam, and medical decision-making, as follows:

History: Detailed
HPI: quality, severity, duration, modifying factors, context, associated signs and symptoms = Extended
ROS: Constitutional, neurological = Extended 
PFSH: 1 element (past history) = Pertinent
Exam: None that can be used in counting the elements
Medical Decision-Making: Low
Established problem, worsening = 2 points
Data: none
Risk: Worsening problem and prescription drug management = moderate
Code: 99213.

Without knowing how much of the 25 minutes the ob-gyn spent counseling, the key documented elements support 99213, not 99214.

Solution: Adding the actual time that the doctor spent on counseling would indicate that the encounter meets time-based coding’s greater than 50 percent on counseling/and or coordination of care criteria and would therefore justify a 99214 for this case.