Pain Management Coding Alert

Here’s why a note documenting counseling/coordination time could make your claim.

If you are coding for standard evaluation and management (E/M) services, you’ll typically choose the level of service based on three key components: history, examination and medical decision-making (MDM). There are times, however, when you would not choose an E/M code based on these components.

When? If counseling or coordination of care (or both) are the major component of the E/M, you might be able to code using the counseling exception. This practice could net your practice higher reimbursement, since choosing an E/M code based on time typically results in a higher-level code.

While potentially profitable, the counseling exception can be dangerous if you misuse it. Check out what these experts had to say about the counseling exception and how to apply it properly.

Check Total Encounter Minutes First

The counseling exception is in play when 50 percent or more of the total encounter time is spent face-to-face with the patient on counseling or coordination of care rather than on the actual elements of a traditional E/M service. In these counseling-dominated scenarios, you can use time “to assign the appropriate level of E/M service rather than the three traditional components,” explains Lynn M. Anderanin, CPC, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Ill.

Standard E/M coding: Normally, you’ll code E/M visits based on the aforementioned elements. So if the notes indicate the physician saw an established patient and performed a problem focused history, a problem focused exam, and straightforward MDM, you’d choose 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making…) for the encounter.

Counseling exception coding: If the encounter qualifies for the counseling exception, you could choose an E/M code based on how long the encounter lasted, not the three key elements. So let’s say the physician saw an established patient and performed a problem focused history, a problem focused exam, and straightforward MDM. However, notes indicate that the encounter took 28 minutes, and 15 of those minutes were spent on counseling and coordination of care. In this case, you’d choose your E/M code based on time — most likely 99214 (… a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem[s] and the patient’s and/or family’s needs. Usually, the presenting problem[s] are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family). (Bold type added to emphasize time component.)

Ensure Proper Notes Before Using Exception

In order to code the counseling exception correctly, the medical record for the encounter must clearly indicate that the physician spent at least half of the encounter time counseling/coordinating care.

The most important piece of info you need in the notes is “details about the minutes spent counseling,” relays Chip Hart, director of PCC’s Pediatric Solutions Consulting Group in Vermont and author of the blog “Confessions of a Pediatric Practice Consultant.”

Ideally, the physician will note a starting and ending time for the counseling, “but it doesn’t always work that way” Hart says. On counseling exception claims, the documentation must at least include a note from the physician such as “XX minutes spent counseling,” Hart continues.

Anderanin agrees, recommending that the physician include documentation that makes it clear that counseling constituted the biggest chunk of E/M time. She recommends including a note to the effect of “The total time spent with the patient was 25 minutes and 20 minutes was spent on counseling the patient on_____________.”

On the claim, Hart recommends you also “include a list of the topics discussed during the counseling — it not only supports the time you spent, but it’s good documentation for reference later,” he says.

Use EHR to Help Track Time … Sometimes

Your electronic health records (EHR) software might be a big help in keeping track of encounter minutes, according to Hart. “EHR should help clinicians keep track of how much time they are spending in the exam room with patients and document accordingly,” he says.

If your EHR software has a proven track record of reliably keeping encounter times — some EHRs are better at this than others — then you might be able to program it to track counseling and coordination of care specifically. Ask your office tech person for help searching for this feature, or call the software company and talk to a representative about the software’s time-tracking features.