Otolaryngology Coding Alert

You-ve got a nifty tool to capture higher-level office visit codes when your ENT provides mainly counseling to a patient or patient's parent.

Overlooking CPT's time rule will land you with lower-level codes for visits involving mainly counseling and little to no history, examination and/or medical decision-making. To start benefiting from using time as the controlling factor, check out these tips.

Before using time as the controlling factor, check off the following requirements. To code based on time in the office setting, the physician must document:

that more than 50 percent of the face-to-face time the physician spent with the patient/and or family is counseling and/or coordination of care, says Lisa Curtis, CPC-I, CPC-E/M, who specializes in E/M audits in the Greeley, Colorado area. "I advise my providers to state the actual time (for instance 45 minutes was spent with the patient in total, 30 minutes in counseling)."

Why: An auditor needs to be able to tell the percent of the visit that the physician spent on counseling and/or coordination of care, explains Patricia A. Trites, MPA, CHBC, CPC, EMS, CHCC, CHCO, CHP, CMP, CEO of Healthcare Compliance Resources in Augusta, Mich. CPT lets you select an office visit code based on time only when the physician 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. If documentation does not specify that the encounter has met the more than 50 percent counseling requirement, you cannot use time as the controlling factor to select the level of E/M service.

a description or summary of the counseling/coordination of care including for instance the topic, advice given and recommendations.

"The physician just can't say -had a long discussion about X,-" Trites warns. "That won't work."

the total time spent with the patient and/or family. If you code based on time, you-ll use this number to select the E/M level.

If the encounter and documentation do not support the above items, switch from using time as the controlling factor.

How: You instead have to code the visit based on the documented history, examination and medical decision-making, says Suzan Berman-Hvizdash, CPC, CPC-EM, CPC-ED, coding and compliance manager with UPMC-UPP Department of Surgery.

Not sure when you-d use time-based coding? Any time a patient and/or family see an otolaryngologist for counseling, the encounter might qualify. Think counseling for cases, such as chronic otitis media or tonsillitis, in which your physician spends the majority of the visit explaining final conservative steps, surgical options, risks, etc.

Example: "A 6-year-old patient does not come into the office for a follow-up with our pediatric ENT," relates Candice Ruffing, CPC, with Drs. Berghash, Lanza & Zeiders in Port St. Lucie, Fla. "The MD spends 25 minutes face-to-face with the parents going over test results," the benefits and risks of surgery, the parents finally decide on surgery and the physician coordinates the surgery. How would you code this visit?

Solution: Provided the physician summarizes the counseling, you would select the E/M code based on time and report 99214 (Office or other outpatient visit for the evaluation and management of an established patient - - physicians typically spend 25 minutes face-to-face with the patient and/or family -). This visit qualifies for time-based counseling.

Reason 1: Going over test results, discussing surgical options, and coordinating surgery counts under counseling. Counseling consists of the physician discussing with the patient and/or family one or more of several areas including diagnostic results, prognosis, risks and benefits of management (treatment) options, importance of compliance with chosen management (treatment) options, according to CPT's E/M services guidelines.

Reason 2: Because the patient is not present at the visit, 100 percent of the encounter is spent on counseling.

You have one less obstacle when coding based on time for pediatric patients than for adults.

AMA guideline: CPT allows time-based coding when counseling dominates the physician/patient and/or family encounter, meaning the patient does not have to be present.

CMS requirement: Medicare, however, only allows time-based coding when the patient is present (Medicare Claims Processing Manual section 30.6.1C "Selection Of Level Of Evaluation and Management Service Based On Duration Of Coordination Of Care and/or Counseling.").