Oncology & Hematology Coding Alert

Question: How can we effectively report for counselling services of our provider? Is counselling a part of E/M service?

Georgia Subscriber

Answer: When you are reporting a standard evaluation and management (E/M) service, you’ll choose the level of service based on three key components: (1) history, (2) examination and (3) medical decision-making (MDM).

Standard E/M coding:  If the clinical note indicates that your physician saw an established patient and performed a problem focused history, a problem focused exam, and straightforward MDM, you choose to submit code 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making…) for the encounter.

However, you may not always choose an E/M code based on these typical components. This exception applies to coding for counselling services. If the encounter qualifies for the counseling exception, you could choose an E/M code based on how long the encounter lasted, not the three key elements. For example, you may read that your physician saw an established patient and performed a problem focused history, a problem focused exam, and straightforward MDM. However, notes indicate that the encounter took 28 minutes, and 15 of those minutes were spent on counseling and coordination of care. In this case, you’d choose your E/M code based on time — 99214 (… a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem[s] and the patient’s and/or family’s needs. Usually, the presenting problem[s] are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family) for an established patient seen in an outpatient or office setting.

Ensure proper notes before using exception: In order to code the counseling exception correctly, the medical record for the encounter must clearly indicate that the physician spent at least half of the encounter time counseling/coordinating care. Your electronic health records (EHR) software might be a big help in tracking the amount of time for the encounter and the portion spent counseling or coordinating care. For compliant documentation and appropriate support for coding by time, the content of the counseling/coordination of care must be clearly documented in the visit note in order to qualify for this exception.

Remember, the time must be face to face with the patient in the office or outpatient clinic. In the hospital, the time may be face to face and include unit/floor time spent in these activities when the physician’s focus was for that patient’s care.