Otolaryngology Coding Alert

As long as the patient is present, CMS allows you to bill an E/M code based on time.

It happens frequently—a patient presents with her family members, who want to discuss how to care for the patient’s condition. The doctor spends most of his time discussing care with the family rather than the patient, leaving coders to wonder how to report the service—should you bill a counseling code, an E/M code, or some other combination? Fortunately, if you can document time-based services, then you are on the road to reporting family visits when the patient is present and the discussion includes counseling on the issues related to the patient’s care.

Watch the Clock

Your best bet when discussing care with a patient and her family is to bill an E/M service (99201-99215) based on time. Because the doctor is performing counseling based on an active condition that the patient has, you are justified in reporting the appropriate E/M code based on the total time of the visit and the amount of time spent performing face-to-face counseling or coordinating care.

When you’re billing based on time, CPT®  defines “face-to-face time” as “only that time spent face-to-face with the patient and/or family. This includes the time spent performing such tasks as obtaining a history, examination, and counseling the patient.” Because CPT® uses the language “with the patient and/or family,” it’s clear that you can discuss the care with the patient’s family and not just with the patient to count it toward the time-based E/M code.

AMA and Medicare says: When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or for inpatient, floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services.

If you are selecting a code based on time, the medical record should show three pieces of information, says Part B MAC WPS Medicare in its “Time-Based E/M Services” Fact Sheet. “The total time of the visit, the time or percentage of the visit spent in counseling/coordination of care and the nature of the counseling/coordination of care. It is suggested that the nature of the counseling/coordination of care be documented with bullet points for each topic, at a minimum. When the physician uses the total minutes or the clock time is a personal decision. Medicare needs to be able to see the three pieces of documentation as listed above.”

Consider These Examples

Several scenarios below serve to illustrate different options applicable to counseling coding and documentation.

Example 1: A 78-year-old established male patient with Alzheimer’s presents to your office with his son to discuss a neoplasm in the patient’s ear. The otolaryngologist performs a biopsy and then discusses how the son can care for the resulting wound, alternative plans of care should the biopsy come back with a malignant diagnosis and also shares information about what can be done to deal with the fact that the patient has stopped wearing his hearing aid and refuses to put it in, but can’t hear without it. This is all documented in the chart. The provider documents that the face-to-face encounter included a total time of 45 minutes, 35 minutes of which is spent counseling the patient and his son.

Coding Solution:  For this office visit, you can report 99215 (Office or other outpatient visit for the evaluation and management of an established patient … Typically, 40 minutes are spent face-to-face with the patient and/or family) based on the amount of time spent with the patient in counseling/coordination of care, assuming your documentation meets the guidelines (see below).

Example 2: A nine-year-old patient presents after referral by a pediatrician due to recurrent ear infections. The otolaryngologist examines the patient and recommends tubes, but the parents are reluctant to schedule the procedure because the patient has autism and they don’t want to put her through a surgery. The ENT documented that he spent a total 25 minutes during the visit, of which 18 minutes were spent counseling the patient and her parents about the alternatives to ear tubes and the potential pros and cons of the procedure. The alternatives, along with the pros and cons, are all documented in the chart with bullet points in the chart.

Coding Solution: You can report 99214 (Office or other outpatient visit for the evaluation and management of an established patient … Typically, 25 minutes are spent face-to-face with the patient and/or family) for the encounter, since the doctor spent at least 25 minutes with the patient and documented that more than half of that time was spent counseling the patient.

Ensure Crystal Clear Documentation

Before using time as the controlling factor, check off the following requirements that must be documented based on CMS guidelines

1. The total time spent with the patient
2. That more than 50 percent of the face-to-face time the physician spent with the patient/and or family is counseling/coordination of care. For instance, “Saw the patient and his son for 30 total minutes face-to-face; 25 minutes of that visit was spent in counseling concerning ….”
3. A description or summary of the counseling/coordination of care provided. For Example One above, you could consider, “Counseled the patient and his son to address coping strategies for the patient’s refusal to wear his hearing age due to his Alzheimer’s disease. Also discussed aftercare for the wound following the patient’s biopsy, and discussed alternative patient bathing strategies in light of the wound.” This list can easily be added into the chart using bullet points.

Red flag: Provider documentation such as “I had a lengthy discussion...” or “I spent a great deal of time with the patient discussing...” does not support using the dominant counseling/coordination of care as the basis for level of E/M service. You should only select an office visit code based on time when your clinician spends more than 50 percent of the face-to-face time with the patient and/or family member on counseling and/or coordination of care.

Key: Medical necessity must also be a key factor in your code choice. Be sure that the time spent with the patient or her family is warranted. Just because the patient and provider talked for a long time doesn’t mean it was medically necessary to do so.

What If the Patient Isn’t Present?

If the patient’s children, parents, or spouse present to the practice to discuss the patient’s condition with the otolaryngologist and the patient is not present, you cannot bill Medicare using the E/M codes. Although CPT® rules support reporting the E/M codes without the patient present, CMS sings a different tune, stating that the patient has to be present. However, many private insurers will allow you to bill for the visit with the family based on time, so check individual payer policies before you bill.