Oncology & Hematology Coding Alert

Question: What is the counseling exception, and what does it means for coders? Can we include the counseling time when choosing E/M Codes? How does it impact coding? What are some other examples that might result in the counseling exception?

Alabama Subscriber

Answer: A counseling exception is a situation where counseling is the major portion of time the billing provider spent face to face (office) or on the nursing unit (hospital) during patient’s visit. When the time spent delivering the E/M visit is dominated by counseling rather than performing the key components of history and examination, CPT^® permits selecting the level of E/M services based on the total face-to-face time. However, you will need to ensure you have all of the documentation supporting the service and its need.

Remember: You must remember to check the clinical notes for evidence that face-to-face time and counseling time are in the record.

In some cases, counseling time can lead to higher-level E/M services as the counseling time adds to the service provided. Your physician may document the counseling along with the time spent for history, physical examination, and decision making.

Example: The physician performs a problem-focused history and straightforward MDM on an established patient with multiple myeloma, which takes 10 minutes. After those services, the physician spends 17 minutes counseling the patient. This encounter was 27 minutes total, with more than half of that time (17 minutes) devoted to counseling or coordination of care. In this case, you can choose an E/M code based on encounter time rather than the history, physical and MDM components. That means you could report 99214 (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 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 the encounter if the physician documents the total time, the time spent counseling, and illustrates a brief synopsis of what was discussed during the counseling.

If you did not employ the counseling exception in this instance, you would have reported 99212 (… a problem focused history; a problem focused examination; straightforward medical decision making. 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 self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family).

Here are examples of counseling exception E/Ms. You should ensure that the physician’s services and documentation satisfy the exception requirements:

• Return visit to discuss significant or complex test results.
• Educating the patient about how to monitor symptoms and biomarkers after being diagnosed with cancer in an earlier visit.
• Discussing with the patient or family (in the case of a minor) treatment options after a diagnosis of cancer.
• A patient of lung cancer who is a chronic smoker and needs guidance on quitting smoking and the possible benefits it can have for the lung cancer.
• An elderly patient may need help to plan medication and understand the schedule of chemotherapy.

Remember: These are only examples of potential counseling exception E/Ms. Each encounter is different.  Be sure that all of the counseling exception rules are met before employing this coding technique.