Otolaryngology Coding Alert

Refer to the 'reference time' for counseling and coordination of care

When reporting services that count on time as a key component, you should remember that the physician must maintain careful documentation of the actual time he spends with the patient or performing relevant services.
 
In addition, coders have to know when time may apply and how much time is enough to qualify for a given level of service.

Example 1: Time-Based E/M Counts on Counseling

You can code an E/M service based on time when the physician spends more than 50 percent of his face-to-face time with the patient (for outpatient services) or floor time (for inpatient services) providing counseling and/or coordinating care, 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. CPT guidelines stress, however, that to code by time the physician must clearly document the extent of counseling and the total time involved.

How to use the reference time: For most E/M codes, CPT lists the time the physician usually spends rendering the service. For example, for established patient code 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...), CPT states, -Physicians typically spend 25 minutes face-to-face with the patient and/or family.- This is called the -reference time.-

Example: Your otolaryngologist completes an expanded problem-focused history and examination (enough for a level-three visit) on an established patient with chronic ethmoidal (473.2) and frontal sinusitis (473.1), but spends a total of 25 minutes with the patient and documents that he spent 18 of those minutes providing counseling on the surgical versus non-surgical options for treating the condition. Because more than 50 percent of the visit consists of counseling, you can use the total time to determine the level of service. In this case, you could report 99214--which pays about $35 more than 99213.

Example 2: Critical Care Time Is Cumulative

The physician must spend a minimum of 30 minutes administering critical care services before a visit qualifies as critical care as described by 99291, according to CPT. For critical care services lasting fewer than 30 minutes, you should choose an appropriate E/M service code, says Susan Allen, CPC, compliance coder with JSA Healthcare in St. Petersburg, Fla.

You may count toward critical care time spent -engaged in work directly related to the individual patient's care whether that time was spent at the immediate bedside or elsewhere on the floor or unit,- according to CPT [emphasis added].

For instance: Time the surgeon spends reviewing tests or discussing the patient's condition with other staff, documenting critical care services, or gathering information from family or surrogate decision-makers when the patient is unable to participate in discussions may count toward critical care, even though these activities may not occur at the patient's bedside.

The time the physician may count toward critical care need not be contiguous. -The time requirement is cumulative for a single date of service,- Allen says. -But you should document well any time the physician spends directly relating to the patient's care.-

In other words: If the physician provides one hour of critical care to stabilize the patient, but the patient's condition deteriorates later that same day and the physician must provide another hour of service, you may report 99291 (for the first hour) and 99292 x 2 (for the remaining hour), even though the services was not continuous.

Learn more: Be sure to read next month-s Otolaryngology Coding Alert for complete and important details on how to report critical care services.

Example 3: For Medicine Codes, Meet 1/2 the Time

For time-based codes in the -Medicine- portion of CPT, such as 92620 (Evaluation of central auditory function, with report; initial 60 minutes) and 92621 (... each additional 15 minutes), the physician should provide the service for at least half of the listed time before you can report the service, Jandroep says.

Example: To report 92620 properly, the physician should spend at least 30 minutes rendering the service. Anything less would probably indicate a cursory service that should be included in an E/M visit.

In addition, if the physician wanted to report 92620 and 92621, he would have to record a minimum of 68 minutes providing a central auditory evaluation: 60 minutes to report 92620 and an additional eight minutes (about half of 15) to report 92621.

Document All Times Precisely

The most important part of coding by time is having complete and adequate documentation of the visit--including documentation of the total visit time and the total time the physician spends counseling, says Lynn M. Anderanin, CPC, director of coding and appeals at Healthcare Information Services in Des Plaines, Ill.

In a best-case scenario, you would like to know:

1. Beginning and ending time of the counseling and/or coordination of care, or critical care. This is crucial to determine if the counseling accounted for more than half the visit, or totaling the critical care time.

2. Beginning and ending time for the overall face-to-face visit.

3. Details about the counseling session's content. Auditors may consider a claim fraudulent if you coded by time but your physician only documented -spent time counseling.- The physician should provide a summary of what the counseling or coordination of care involved, says Jaime Darling, CPC, a certified coder with Graybill Medical Group in Escondido, Calif.

At minimum, you would want the start and stop time of the entire session, as well as the time and content of the counseling.

Tip: Placing a clock on the examining room wall may remind the doctor to document time, while also making it easier to do so.
 
Don't -fudge- it: If your physician does not include enough documentation about counseling and/or co-ordination of care during the patient's visit, you may have no choice but to code a lower-level E/M service.