Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist spends a lot of time discussing treatment options, imaging results, and other issues with patients. How should she document this to support coding E/M based on time?

Arizona Subscriber

Answer: When counseling and/or coordination of care take up more than 50 percent of the encounter, and you choose to code based on time, CPT®'s E/M guidelines tell you "the extent of counseling and/or coordination of care must be documented in the medical record." Medicare's 1995 and 1997 E/M documentation guidelines (www.cms.gov/MLNEdWebGuide/25_EMDOC.asp) add that the physician should document the total length of the encounter, how much of the total time was spent in counseling and "describe the counseling and/or activities to coordinate care."

Remember: In the office or outpatient setting, you should count only face-to-face time that the physician spends with the patient. In the hospital or in a nursing facility, you may count floor/unit time, according to both CPT® guidelines and Medicare's documentation guidelines. CPT® guidelines describe the encounter as a "physician/patient and/or family encounter."

Example: The physician may document spending 20 minutes of a 25-minute encounter with an established patient discussing test results (she should be specific when documenting the test results) and going over the likely outcome of a procedure. The physician fills in the remaining details of the visit, as appropriate. In this case, based on the 25-minute session (total time), report 99214, which CPT® specifies as usually lasting 25 minutes:

• 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 providers or agencies are provided consistent with thenature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.