Pediatric Coding Alert

One hour E/M visit? You don't warrant a prolonged service code yet, experts say.

If coding for time-based E/M services still has you scratching your head, we've got the solution. The following three frequently-asked questions will get you on the straight and narrow.

Last month's article "CPT Allows You to Select Code Based on 'Closest Typical Time' When Counseling Dominates Visit" prompted several follow-up questions from our subscribers. We selected the top three and broke down the coding regs to give you the lowdown.

Get to Know the 'Midpoint' Coding Rule

Question 1: I was glad to read that CPT has put into writing the fact that coders can pick the "closest typical time" when using time to choose an E/M level, but I've also heard in seminars that we can "round up" from a 31-minute visit to make it a full hour. Is this true, and if so, why isn't this in CPT?

Answer: This is true, and the information is in CPT, albeit not in the E/M guidelines on page 7 of CPT's professional edition, which is where the other time-based coding instructions are. Instead, turn to page xii in the Introduction section of the CPT manual, and under the heading marked "Time," you'll find the following instruction:

"A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than the midpoint between zero and sixty minutes)."

Keep in mind: Although CPT directs you to "round up" to the next code after reaching the midpoint, it also advises, "When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the time closest to the actual time is used," so keep in mind that this rule trumps the "rounding up" regulation.

Does One-Hour E/M Warrant Add-on Prolonged Service Code?

Question 2: Our physician provided a one hour E/M service, most of which was spent on counseling, so we reported 99215 and one unit of +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour). An outside auditor came to our practice and said we should not have reported 99354, and told us to write our payer and give back the reimbursement we received for this extra charge. Is this accurate?

Answer: Your auditor is correct. You can only add +99354 if your physician spent an additional 30 to 74 minutes beyond the typical time of 40 minutes allotted for 99215. In your case, the physician spent a total of 60 minutes on the service, but you'd need to spend at least 70 minutes to report 99215 with 99354.

Example: You schedule an hour with a child and his parent because the child is having behavior problems at school and at home. When the child and his mother arrive, they bring extensive records from school for review. The pediatrician ends up spending an hour and 15 minutes face-to-face during the visit, going over the problems and counseling the family on potential diagnoses and solutions. "Counseling" is an important word to use related to time-based coding. It is included as an appropriate service to support coding based on time.

Coding advice: In this example, you'll report one unit of 99215 to cover the first 40 minutes, plus one unit of 99354 for the extra 35 minutes of faceto- face prolonged services, says Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville.

Count Your Time, Even for Preventive Visits

Question 3: We have successfully used time as the controlling factor in choosing the most accurate problem-oriented CPT code (99201-99215), but can we use time to select a preventive medicine code from the 99401-99404 series?

Answer: Yes, you can use this rule when using preventive service codes.

Example: A child's deployed parent is expected to return home. The pediatrician discusses possible issues, suggests reacclimation techniques, and identifies problem warning signs. For a session on preventing and reducing adjustment problems that lasts 10 minutes, you would code 99401 (... approximately 15 minutes) with V61.02 as your diagnosis code.

Code 99401 is appropriate for this situation involving specific significant anticipatory counseling related to the anticipated family disruption due to the deployed parent returning home.

Note: Remember the critical importance of documentation related to coding based on time. The physician should note total face-to-face time, minutes (over 50 percent) spent counseling/coordination of care, and should refer to general issues discussed.