Otolaryngology Coding Alert

Question: During an office visit, the doctor documents that he spent 25 minutes with the patient. He then documents that 50 percent of the visit involved counseling the patient. Can I report 99203 based on time?

Illinois Subscriber

Answer: The specifics about the patient encounter aren’t completely clear based on the question. The response to this question is based on the assumption that 25 total minutes were spent with the patient, rather than 25 minutes spent counseling, alone.

Based on the circumstances of the visit, you may not use time to determine the evaluation and management (E/M) code in this situation since this time counseling the patient did not exceed the 50 percent threshold. CPT^® guidelines instruct coders to consider time as an option when the counseling involves greater than 50 percent of the total time of the visit.

Assume the physician did examine the patient for, say, 51 percent of the total time of the visit. You then need to check the CPT^® code time estimations for code 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity…). As you will see, the time estimation for 99203 is 30 minutes. Since the 25-minute total doesn’t meet or exceed that threshold, you may not code up to 99203, even if the physician exceeded 50 percent of the visit counseling.