Pediatric Coding Alert

Counseling exception can net you higher-level E/Ms … in specific situations.

When your pediatric provider performs an office evaluation and management (E/M) service, you’ll typically choose a code based on the three key components of an E/M: history, examination, and medical decision making (MDM).

Except when …: Counseling and/or coordination of care dominates the visit. If the E/M session meets certain parameters, you might be able to use the counseling exception, which would likely lead to a higher-level E/M code for your provider’s service.

Read on for information on how to apply the counseling exception and max out your rightful reimbursement for each and every E/M.

Meet Time Threshold First

Simply put, the counseling exception “means that more than 50 percent of the total [E/M] time spent in patient care involves counseling or coordination of care by the physician,” explains Donelle Holle, RN, President of Peds Coding Inc, and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. When the counseling exception applies, you will be able to choose your E/M code based on encounter time — not on the three key components of history, exam, and MDM.

Benefit: In most situations, you’ll be able to code for higher-level E/Ms when you apply the counseling exception.

For instance, if notes indicate that the physician performed a problem focused history and exam, along with straightforward MDM, for an established patient, you’d typically report 99212 (Office or other outpatient visitfor the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problemfocused history; a problem focused examination; straightforward medical decision making …).

If the visit qualifies for the counseling exception, however, you might be able to report a higher-level code. Let’s say that after the history, physical, and MDM, which takes 10 minutes, the provider counsels the patient and her family on how to care for her asthma. Notes indicate that the counseling and coordination of care conversation lasted 15 minutes. This visit qualifies for the counseling exception, as the provider spent more than 50 percent of the total time on counseling and care coordination.

So instead of coding for the level of service (99212), the counseling exception would allow you to report 99214 (… a detailed history; a detailed examination; medical decision making of moderate complexity …) for this E/M, as the visit lasted 25 minutes and the descriptor for 99214 reads “Typically, 25 minutes are spent face-to-face with the patient and/or family.”

Peds Coders: Be Especially Aware of Exception Opportunities

While some specialties might not see many counseling exception E/M claims, pediatrics is a different animal. “In pediatrics, [counseling exception E/Ms] happen all the time,” relays Chip Hart, director of PCC’s Pediatric Solutions Consulting Group in Vermont and author ofthe blog “Confessions of a Pediat­ric Practice Consultant.”

General exception examples: “A kid comes in for otitis, but the mom wants another 15 minutes to discuss her upcoming divorce and the effect on her children. A diabetes visit leads to a long discussion about changing bad dietary habits, etc.,” Hart explains.

While any patient problem could result in a counseling exception visit, the rule is most often used for “behavioral visits — ADD, depression, eating disorders, etc.,” says Hart.

Also, keep in mind that the patient does not have to be present during the counseling/coordination of care. If you meet with a mother and father to discuss their child’s potential depression or drug use, for example, this time would be applicable to the counseling time for the E/M session.

Check for Language that Might I.D. Exceptions

If you’re a coder scouring E/M encounter notes for counseling exception evidence, you might see language to this effect, according to Holle: “‘I had a lengthy discussion …; I talked at length,’ etc. Whenever [providers] make that statement, it means they may have had a higher level of care if billed using time as a key factor,” she says.

What successful documentation boils down to is details about the minutes spent counseling, according to Hart. “Ideally, you’d have a starting and ending time [for the counseling], but it doesn’t always work that way. But anything short of ‘XX minutes spent counseling’” won’t stand up to scrutiny from payers, Hart continues.

Use EHR — But Carefully

Your practice’s electronic health records (EHR) “should help clinicians keep track of how much time they are spending in the exam room with patients and document accordingly,” reminds Hart. Don’t let the machines rise to power in your E/M time documentation, however. “HER systems that automatically track how much time you spent with a patient are notoriously inaccurate,” Hart warns.

Wise redundancy: Use your EHR’s time-tracking component, as “your system can provide an easy place to track the start and end of the counseling, giving you a better position in an audit,” says Hart. But if you have any doubt as to whether the EHR time documentation is accurate on a counseling exception claim, you might want to check with the provider before submitting the claim.