Pediatric Coding Alert

Once you’ve answered the quiz questions on page 75, compare your answers with the ones our experts have provided below.

Answer 1:
The short answer to this question is that “you can base an E/M service on time when the provider indicates in their documentation that they used time to determine their level of care,” says Donelle Holle, RN, President of Peds Coding Inc., and a health care, coding, and reimbursement consultant in Fort Wayne, Indiana.

The longer answer is that, in order to use time to calculate the correct level of E/M service, both coders and providers must ensure:

• The service must be face-to-face with the patient and/or the patient’s family.
• The time in the encounter must be spent counseling or coordinating patient care.
• The time spent counseling or coordinating care must be more than 50 percent of the total encounter time.
• The provider must provide documentation of the counseling performed.

Answer 2:
In terms of documentation, CPT^® guidelines state that “the extent of counseling and/or coordination of care must be documented in the medical record.” However, “statements in the medical record to the effect that the provider engaged in a lengthy conversation with the patient do not correspond to a specific E/M level and are open to interpretation,” notes Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

Instead, “the best way to document for time is to state the total amount of time spent with the patient and/or family and note the main topics covered in the encounter, making sure that the note has enough detail to justify the 50-percent rule,” cautions Falbo.

Answer 3:
“The answer to this question is, yes and no!” says Holle. “If the NPP is billing under his or her own name and ID, then, yes, the NPP can bill using time just as any physician,” Holle explains. “However, if they are billing incident-to for their services — in other words, they are the rendering provider and there is a supervising provider who is the billing provider — then they are not allowed to bill based on time as the key factor,” Holle elaborates.

Answer 4:
There are two ways to answer this. If coding by time, you would have to code 99214 (Office or other outpatient visit for the evaluation and management of an established patient. … Typically, 25 minutes are spent face-to-face with the patient and/or family), as “even if the total visit time was 40 minutes, which is the threshold for 99215 [… Typically, 40 minutes are spent face-to-face with the patient and/or family.], the counseling was only 15 minutes. To code 99215, the time would have to be more than 21 minutes, or more than 50 percent of 40 minutes,” Holle explains.

However, in situations such as this, “I would recommend not using time at all but using medical decision making as one of the two components needed to ensure the medical necessity of the visit supports the CPT^® code billed,” says Falbo. Depending on the circumstances of the encounter, that may lead to billing the higher 99215 E/M level.