Pain Management Coding Alert

Question: Could you explain the counseling exception, and how it relates to office evaluation and management (E/M) coding?

Nevada Subscriber

Answer: When your provider performs an office E/M service, you’ll typically choose a code based on the three key components of an E/M: history, examination, and medical decision making (MDM).

Except when …: Counseling and/or coordination of care dominates the visit. If the E/M session meets certain parameters, you might be able to use the counseling exception, which would likely lead to a higher-level E/M code for your provider’s service.

Simply put, the counseling exception “means that more than 50 percent of the total [E/M] time spent in patient care involves counseling or coordination of care by the physician,” explains Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. When the counseling exception applies, you will be able to choose your E/M code based on encounter time — not on the three key components of history, exam, and MDM.

Benefit: In most situations, you’ll be able to code for higher-level E/Ms when you apply the counseling exception.

For instance, if notes indicate that the physician performed a problem focused history and exam, along with straightforward MDM, for an established patient, you’d typically report 99212 (Office or other outpatient visitfor 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 …).

If the visit qualifies for the counseling exception, however, you might be able to report a higher-level code. Let’s say that after the history, physical, and MDM, which takes 10 minutes, the provider counsels the patient on managing her chronic pain. Notes indicate that the counseling and coordination of care conversation lasted 15 minutes. This visit qualifies for the counseling exception, as the provider spent more than 50 percent of the total time on counseling and care coordination.

So instead of coding for the level of service (99212), the counseling exception would allow you to report 99214 (… a detailed history; a detailed examination; medical decision making of moderate complexity …) for this E/M, as the visit lasted 25 minutes and the descriptor for 99214 reads “Typically, 25 minutes are spent face-to-face with the patient and/or family.”  

---