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Oncology & Hematology Coding Alert

If Counseling Extends Encounter, Shelf Prolonged Service Codes

Published on Sun Mar 20, 2005

Sometimes, raising the E/M level is the better option

In certain cases of longer-than-normal evaluation and management services, you may be able to increase the E/M level - but the visit must meet certain conditions before you do this.
 
Raise the E/M level when the oncologist spends more than 50 percent of the face-to-face time counseling and coordinating care for this visit, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.
 
For example, the oncologist's notes indicate that he performed a level-four new patient E/M service in the office. Due to the patient's anxiety over the prospect of cancer, the encounter took 80 minutes and the oncologist spent 45 of those minutes counseling the patient. In this case, you should raise the E/M level. On the claim:
 

  •  report 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity) for the E/M service.
     
  •  include specific documentation on the 45 minutes of counseling to strengthen your claim.

    Payers Serious About Counseling Documentation

    In the above example, you must include thorough documentation of the counseling time, or payers will wonder why you reported 99205 for what appears to be a 99204 service. Include documentation of this sort to strengthen your proof that counseling dominated the visit:
     
    1. Notes detailing total encounter time. For example, "Conducted E/M service for patient, and intensive counseling, from 11 a.m.-12:24 p.m."

    2. Notes detailing standard E/M time and counseling time. For example, "Performed standard E/M 11-11:45 a.m. ... Patient then confessed extreme anxiety and worry because she may have cancer. Counseled patient on issue 11:46 a.m.-12:24 p.m."

    3. Any other notes on counseling session. On the claim, include whatever notes the oncologist writes about specifics of the counseling or the patient's condition. For example, if the oncologist reviewed literature with the patient about cancer care or directed her to any outside support resources, you should include this information on the claim.

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