Oncology & Hematology Coding Alert

Increase your level of service with concise time documentation

A thorough knowledge of time components for CPT evaluation and management codes is vital to an office's fiscal health. If you don't know all about how time spent counseling affects E/M codes, you may be settling for less money than you deserve.
 
Did you know? You can code an E/M service based on time when the physician spends more than 50 percent of his face-to-face time with the patient providing counseling and/or coordinating care.
 
CPT states if counseling and/or coordination of care constitutes more than 50 percent of the physician/patient encounter, you may use time as "the key controlling factor to qualify for a particular level of E/M services." CPT also stresses that to code by time the physician must clearly document the extent of counseling and the time involved.

Check E/M Codes' 'Reference Time'

For most E/M codes, CPT lists the time the physician usually spends rendering the service. For example, for established patient code 99214, CPT states, "Physicians typically spend 25 minutes face-to-face with the patient and/or family." This is called the "reference time."
 
Example: Suppose your physician only completes an expanded problem-focused history and examination on an established patient (enough for a level-three visit), but spends a total of 25 minutes with the patient and documents that he spent 18 of those minutes providing counseling. Because more than 50 percent of the visit consists of counseling, you can use the total time to determine the level of service. In this case, you could report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity) for the E/M service
 
Payoff: CPT code 99214 pays about $35 more than 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity).

Document and Verify All Times Involved

The most important part of coding by time is having complete and adequate documentation of the visit - including documentation of the total visit time and the total time the physician spends counseling, says Lynn M. Anderanin, CPC, director of coding and appeals at Healthcare Information Services in Des Plaines, Ill.
 
If you want to be able to code based on time, make sure your physicians know to document the following:

 1. Beginning and end time of the counseling and/or coordination of care. This information is crucial for determining if the counseling accounted for more than 50 percent of the visit.

 2. Beginning and end time of the overall face-to-face visit. "I've actually gotten some of my physicians in the habit of writing the time they go into a room and writing the time they step out of the room - and that often helps us prove that 50 percent of the visit or more was spent on counseling," says Jaime Darling, CPC, with Graybill Medical Group in Escondido, Calif.

 3. Details about the counseling session's content. Auditors will consider a claim fraudulent if you coded by time but your physician only documented "spent time counseling." The physician must at least provide a summary of what the counseling or coordination of care involved, Darling says.
 
Counseling may involve services such as discussion of test results and prognosis, instructions and/or education for self-care or medication, and planning for future services, says Judy Richardson, MSA, RN, CCS-P, senior consultant with Hill & Associates in Wilmington, N.C.

Now You're Ready to Calculate

If your physician provides all the necessary time documentation, you then need to calculate the total visit minutes and total counseling minutes to prove that counseling dominated the visit.
 
Play it safe: If your physician does not include enough information about the patient's visit, you may have no choice but to code a lower-level service. Be careful what you count as "counseling": Time spent taking the patient's history or performing an examination does not count as counseling time.

Take Advantage of 2 Main Benefits

CPT's code-by-time catch may allow you to justify a higher-level E/M code or to report a visit that lacks one of the required key components (history, exam and medical decision-making, or MDM) if counseling dominates the visit, Darling says.
 
1. Higher level of service: For example, an established consult patient with bronchial cancer returns to the oncologist's office to discuss the results of previously administered diagnostic tests. The oncologist and patient spend an hour and 25 minutes discussing test results, treatment options and preventive measures to alleviate symptoms.
 
The history, exam and MDM are minimal, but because counseling and coordination of care dominated the encounter, you can use time as the controlling factor when assigning the E/M level.
 
In this case you can: