Ophthalmology and Optometry Coding Alert

Time - rather than the key E/M components of history, exam and medical decision-making (MDM) - can be the determining factor when choosing an E/M service level, allowing the physician to report a higher-level code than the key components would warrant alone.   

But you need to know the rules around this to avoid going afoul and drawing undue attention to your practice.

Step One: Know the Requirements
 
According to CPT guidelines, when counseling or coordination of care dominates the physician/patient encounter (that is, comprises more than 50 percent of the visit), "time may be considered the key or controlling factor to qualify for a particular level of E/M services." Counseling and coordination and care may include discussion with the patient about one or more of the following areas: diagnostic results, impressions and/or recommended diagnostic studies, prognosis, risks and benefits of treatment options, instructions for treatment and/or follow-up, importance of compliance with chosen treatment options, risk factor reduction, and patient/family education.
 
To determine the appropriate E/M level for the time spent with the patient, you must check the reference time included in the CPTdescriptor for each code, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. For instance, the descriptor for 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) states, "Physicians typically spend 10 minutes face-to-face with the patient and/or family," while the descriptor for 99254 (Initial inpatient consultation for a new or established patient ...) specifies, "Physician typically spend 80 minutes at the bedside and on the patient's hospital floor or unit."
 
For example, an ophthalmologist performs what would generally be coded a level III E/M service, and then spends an additional 15 minutes with the patient and his spouse to offer more information about the patient's condition and counseling them about the upcoming procedure.
 
The physician spends 25 minutes total: 10 minutes to examine the patient and 15 minutes discussing the risks and benefits of surgery, other treatment options, and preventive measures to alleviate discomfort before and after surgery, in addition to the E/M service.
 
The history, exam and MDM are standard in this case, but because counseling and coordination of care dominated the encounter, you can use time as the controlling factor when assigning the E/M service level. Total all of the face-to-face time the physician spends with the patient, noting the time spent for each portion of the visit.
 
To determine the appropriate E/M level based on the time spent with the patient, you must check the reference time included in the CPT descriptor for each code. For instance, the descriptor for 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) states, "Physicians typically spend 15 minutes face-to-face with the patient and/or family," while the descriptor for 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...) specifies, "Physicians typically spend 25 minutes face-to-face with the patient and/or family."
 
In this case, you could code for a level IV E/M visit (99214), due to the dominance of counseling and coordination of care during the visit and the amount of time it took. This would mean roughly a $27 increase on reimbursement for this visit.
 
Note: Time spent by the technician taking the patient's history or performing screening services such as visual acuity and intraocular pressure does not count toward the physician's face-to-face time.

Step Two: Document Your Work

Documentation is always crucial for time-based E/M services. Most important, the physician should specifically note start and stop times for the patient visit, as well as the portion of the time spent on counseling and coordination of care, Jandroep says. CMS guidelines require that physicians document exact times, and they may have trouble during an audit if they have not noted this information.
 
In addition, physicians should document what issues they discussed in counseling (for example, treatment options, prognosis, etc.). For instance, the physician might note, "20 minutes with patient discussing his role in preparing for surgery, the benefits/risks of surgery, and postsurgical rehabilitation issues."
 
Finally, the surgeon should include the components of history, exam and MDM - even if they are cursory - in the documentation. Good medical record keeping requires that you document relevant and pertinent information, and using time as the determining factor to choose the E/M level does not negate this requirement.