Part B Insider (Multispecialty) Coding Alert

Want to bill for a 99214 or 99215 office visit but can't prove the required level of severity of medical decision-making and physical examination? Don't panic!

If the physician spends more than 50 percent of a visit on counseling, you can bill for the visit based on the time the physician spends face-to-face with the patient instead of the usual MDM, history and exam. For example, you can bill for a 99214 if the physician spends 25 minutes with the patient and 13 of those involve counseling, says Mary Beth Black, senior associate with Medical Management Associates Inc. in Atlanta.

Counseling-based E/M billing isn't a magic bullet, says Cindy Parman with Coding Strategies in Powder Springs, Ga. Most patients whom the physician spends a lot of time counseling will also require a complexity of MDM, because the physician will be discussing treatment options.

"A lot of doctors think it's easier to document on time, but it's not," Parman says. "It's actually harder to document than on history, exam and MDM."

Documentation should include the total length of the visit, the time spent on counseling, and the topics discussed, Black says. These should be as specific as possible. "It doesn't work if you just say, 'Spent 20 minutes on counseling and coordination of care,' " Black says.

The best occasion for this sort of billing is in a follow-up visit, when the patient has had a lab test or biopsy that found a problem. The visit will revolve around discussing more tests and options. "You're not going to do any exam or history, but you do have counseling or coordination of care," Black says. If you spent 20 minutes with the patient, of which at least 11 were counseling, you could bill a 99213.

Expect carriers to be skeptical if you claim that a busy physician spent a whole hour with a patient, of which 35 minutes went to counseling, Parman says. Some physicians include listening to patients' complaints about the magazine selection in their waiting rooms as part of "counseling," but this is wrong, Parman says. "That's customer service. It's not counseling."

The biggest problem Black sees in billing for counseling is when a patient has a fairly minor diagnosis code such as a cold, but the physician claims to have spent 25 minutes. "It probably won't fly unless you have all sorts of other risk factors that you're counseling for," she says. In that case, you'll have to use the different ICD-9 codes to prove the patient needed that much counseling. Possible risk factors that could justify minutes on counseling and coordination of care,' " Black says.

Parman agrees it may be legitimate for a physician to bill for counseling if she spends time with a follow-up patient discussing lifestyle risks. But beware billing for such counseling in successive visits, since there are only so many times you can tell someone to quit smoking and stop eating fatty foods if he didn't listen the first time, Parman says.

Attack of the Clones

Also, if you're going to bill for counseling, beware what the carriers call a "cloned note," Parman says. Some software programs will spit out a generic message that merely says the physician spent 35 minutes doing counseling and coordination of care, the patient asked questions, and the physician answered them to the patient's satisfaction.

One situation in which Parman envisions billing for counseling is if a patient sees an oncologist and discusses treatment options such as chemotherapy and surgery, then the patient returns two weeks later with more questions about those options. "That may be a situation in which the oncologist will just do counseling."