Oncology & Hematology Coding Alert

Question: A patient came for a consultation. The next week the patient came back to further discuss treatment options and so forth, but there was no physical exam. How do I bill for this visit?

North Carolina Subscriber

Answer: You should bill for the first visit with the appropriate code from the 99241 through 99245 range (office consultation for a new or established patient). For the second visit, there are two options. The first option is to determine the evaluation and management (E/M) level, based upon the extent of documentation of the three key components of history, exam and decision-making. The second option arises if the visit qualifies as one where time is the key or controlling factor to qualify for a particular level of E/M service. From your description, this visit meets the criteria for making time the controlling factor.

Choose the appropriate code from 99211 through 99215 or, if the visit is longer than 70 minutes, add the appropriate code from the prolonged services codes, 99354 or 99355. In other words, if the documentation shows the visit lasted 70 minutes, use 99215 and 99354 x 1.

According to the CPT manual, time qualifies as a controlling factor when the visit consists predominantly of counseling or coordination of care. CPT 2000 says, when counseling and/or coordination of care dominates (more than 50 percent) of the physician/patient and/or family encounter time becomes the key component. Since your scenario describes a return to discuss treatment options, this would qualify as a situation when time becomes the key component. Most E/M code descriptions include an amount of time that the physician typically spends with the patient and/or family, defining the time component that will determine the level of service. In the office or outpatient setting, time is measured as the face-to-face time of the physician and patient and/or family.

In an inpatient setting, in addition to time spent face-to-face with the patient, time billed may include the time the physician spends on the floor or unit directly related to the care of the patient. This can be time spent reviewing the chart, discussing the patients care with other care providers, etc., and does not need to be at the patients bedside. When time is the key component, the total length of the encounter and a description of the counseling should be included in documentation.