Part B Insider (Multispecialty) Coding Alert

Proper documentation of time spent on counseling can increase your level of service

You may be settling for less money than you deserve if you don't code by time for your physician's counseling services.

Little-known fact: You can code an E/M service based on time when the physician spends more than 50 percent of his face-to-face time with the patient providing counseling and/or coordinating care.

CPT states if counseling and/or coordination of care constitutes more than 50 percent of the physician/patient encounter, you may use time as "the key controlling factor to qualify for a particular level of E/M services." CPT also stresses that to code by time the physician must clearly document the extent of counseling and the time involved.

The basics: For most E/M codes, CPT lists a typical amount of time the physician usually spends rendering services. For example, for established patient code 99214, CPT states, "Physicians typically spend 25 minutes face-to-face with the patient and/or family."

Suppose your physician only completes an expanded problem-focused history and examination on an established patient (enough for a level-three visit), but spends a total of 25 minutes with the patient and documents that he spent 18 of those minutes counseling the patient. Because more than 50 percent of the visit consists of counseling, you can use time to determine the level of service. In this case, you could report 99214 - which pays approximately $35 more than 99213.

Verify Documentation of All Times Involved

The most important part of coding by time is having complete and adequate documentation of the visit - including documentation of the total visit time and the total amount of time the physician spends counseling the patient, says Lynn M. Anderanin, CPC, director of coding and appeals at Healthcare Information Services in Des Plaines, IL.

If you want to code based on time, make sure your physicians know to document the following:

1. Beginning and end time of the counseling and/or coordination of care. This information is crucial for determining if the counseling accounted for more than 50 percent of the visit.

2. Beginning and end time of the overall face-to-face visit. "I've actually gotten some of my physicians in the habit of writing the time they go into a room and writing the time they step out of the room - and that often helps us prove that 50 percent of the visit or more was spent on counseling," says Jaime Darling, CPC, with Graybill Medical Group in Escondido, Calif.

3. Details on the content of the counseling session. Auditors will consider a claim fraudulent if you coded by time but your physician only documented: "spent time counseling." The physician must at least provide a summary of what the counseling or coordination of care involved, Darling says. Counseling may involve services such as discussion of test results and prognosis, instructions and/or education for self-care or medication, and planning for future services, to list just a few, says Judy Richardson, MSA, RN, CCS-P, senior consultant with Hill & Associates in Wilmington, NC.

Next, calculate: If your physician provides all the necessary time documentation, you then need to calculate the total visit minutes and total counseling minutes to prove that counseling dominated the visit.

Play it safe: In the event that your physician does not include enough information about the patient's visit, you may have no choice but to code a lower-level service.

Take Advantage of 2 Main Benefits

CPT's code-by-time catch may allow you to justify a higher-level E/M code, and also to charge for a visit that lacks one of the required key components (history, exam, medical decision making) if counseling dominates the visit, Darling explains.

1. Higher level of service.

Check out these two examples of how coding by time can increase your level of service:

Example #1: Your physician diagnoses a child with a high lead toxicity level. The physician takes 30 minutes to determine the diagnosis and an additional 45 minutes counseling the parents on how to guard against further lead exposure.

Because of the level of exam, history and medical decision making, you might normally bill 99213 (which includes 15 minutes of face-to-face patient time) for this established patient visit. However, if your physician properly documents the total time of the visit (75 minutes) and separately documents the 45 minutes he spends counseling the patient's parents, you can report 99215 (which includes 40 minutes of face-to-face time) to recoup for all the physician's services.

Drawback: If your physician spends more than 40 minutes with an established patient, or more than 60 minutes with a new patient, even a level five E/M code may not account for the entire length of service.

Solution: If your carrier accepts prolonged service codes (99354-99357), you may want to consider using them in addition to the basic E/M code when your physician renders an extremely long counseling service.
Prolonged service codes are add-on codes, and you should use them if your physician's time with the patient exceeds the time assigned to the E/M visit code you've selected, Anderanin says. Remember, Medicare does not cover prolonged service codes 99358 and 99359 because they represent services that do not require direct physician/patient contact, she adds.

Example #2: Your physician diagnoses a teenager with bronchitis caused by smoking. The physician documents a 10-minute, level-three E/M service to diagnose the bronchitis, and also documents an additional 15 minutes spent counseling the patient on how to quit smoking. The components of the exam may only qualify for a 99213, but you can code by time because a majority of the total visit time was spent counseling - and that bumps you up to a 99214.

2. Visit lacking one required key component.

Physicians often spend time-consuming visits coordinating care for patients with complicated disorders, but they don't always document an adequate history or exam for coding purposes. Even if one required component is completely missing from the visit, the CPT guidelines indicate "you can still code for the visit based on time as long as the physician spends 50 percent or more of his time counseling the patient - whether it's a new or established patient," Darling says.

Check out three examples of how coding by time allows you to bill for an otherwise incomplete E/M visit:

Example #1: An oncologist sees an established patient to discuss her test results and explain that she has breast cancer. The physician performs no physical and only a brief interval history, but documents 40 minutes spent counseling the patient on her prognosis and treatment options and choosing a plan of care. If you code this visit by time, it qualifies for a level-five E/M - 99215.

Example #2: An ob-gyn provider sees a pregnant woman for the first time to discuss and coordinate the plan of care for her pregnancy. The provider takes a comprehensive history, but performs no physical exam during the visit. The documentation indicates a 45-minute total visit time, and the physician devotes 30 of those minutes to coordinating the patient's plan of care. If you code by time for the visit, it qualifies for a level-four new patient visit - 99204.

Example #3: "We have a provider who does diabetic counseling on a regular basis and all she really examines on the patients is their feet," Darling says. If a patient's diabetic condition is under control, the visit pretty much consists of counseling on diet, exercise and medication - and we code for the service based on time, she reports.

Don't forget inpatient services: Coding by time is an opportunity available for all E/M codes, not just basic new and established patient visits. For example, if your physician spends more than 50 percent of an inpatient visit on counseling, you could select the appropriate level of initial hospital care (99221-99223) or subsequent hospital care (99231-99233) based on the total visit time.