Pediatric Coding Alert

Before using time as the controlling factor, check off the following requirements that must be documented:

1. The total time spent with the patient
2. That more than 50 percent of the face-to-face time the physician spent with the patient/and or family is counseling/coordination of care. For instance, “Saw the patient’s mother and father for 30 minutes face-to-face; 25 minutes of that visit was spent in counseling concerning ….”
3. A description or summary of the counseling/coordination of care provided. For the example in our accompanying article, you could consider, “Done to address coping strategies for the patient’s diagnosis of ADHD and treatment options.”

Red flag: Provider documentation such as “I had a lengthy discussion...” or “I spent a great deal of time with the patient discussing...” does not support using the dominant counseling/coordination of care as the basis for level of E/M service. You should only select an office visit code based on time when your clinician spends more than 50 percent of the face-to-face time with the patient and/or family member on counseling and/or coordination of care.

When choosing the level of care, pick the code that is closest to the amount of time spent. For instance, 21 minutes is closer to 99214 then it is to 99213 (which has 15 minutes associated with it) and 33 minutes is closer to 99215 then to 99214.

Key: Medical necessity must also be a key factor in your code choice. Be sure that the time spent with the patient or her family is warranted. Just because the patient and provider talked for a long time doesn’t mean it was medically necessary to do so.