Pediatric Coding Alert

Discover the factor that trumps new patient HEM criteria

One rule supersedes 99201-99205's three component criteria -- and knowing it can make the difference between a reportable and non-reportable E/M service.

Bust This Myth: Elements Always Take Priority

The misconception: Some coders think that to bill an office visit based on time the pediatrician must have previously treated the child. The argument behind this rationale goes something like this: Because a pediatrician must examine a new patient prior to billing for counseling, a new patient office visit ( CPT 99201 - 99205 ) requires all three elements -- history, examination, medical decision-making (HEM).
 
False impact: You cannot bill a counseling session for a new patient unless the child is present (and the pediatrician performs an exam).
 
Before educating her pediatricians on the above advice, one Pediatric Coding Alert subscriber contacted the publication for confirmation. "When you convert to coding based on counseling/coordination of care, I thought the requirements of the 'key components' are no longer a factor," says Kathy Schnaidt, RN, at Fort Collins Youth Clinic in Colorado.
 
And indeed Schnaidt is right. One expert weighs in with documentation on why.

Here's When Time Operates as the Controlling Force

"Time-based coding trumps all," says Richard H. Tuck, MD, FAAP, a nationally recognized coding speaker with PrimeCare of Southeastern Ohio. When counseling and coordinating care is more than 50 percent of face-to-face time in the outpatient setting or floor time in the inpatient setting, time overrides the key components, he says.
 
Good news: You can use time as the controlling force for several E/M services. The rule applies "to new as well as established codes, as well as to consultation codes," Tuck says.
 
Official word: CPT's time-based rule simply says, "When counseling and/or coordination of care dominates the physician/patient and/or family encounter ... then time may be considered the key or controlling factor to qualify for a particular level of E/M services." "No additional requirements are cited in CPT," Tuck say.
 
Simply put: For counseling/coordination of care- dominated visits, you can disregard the key components of history, examination and medical decision-making. "Therefore, the child does not need to be present, even at the new patient visit," Tuck says.
 
Look for varied opportunities to code based on time. "Using time as the controlling force is a very handy way to capture discussions with parents regarding ADHD, learning disabilities, behavioral/school problems, developmental behavior, and complex medical problems," says Peter D. Rappo, MD, FAAP, assistant clinical professor of pediatrics at Harvard University School of Medicine in Brockton, Mass.

Defeat Downcoding With Shorthand Tricks

But time-based coding can add a crux in your paid claims ratio. Insurers that look at diagnoses to support billed levels of service may downcode visits that don't contain what the company considers highly complex ICD-9 codes. You can combat downcoding with two tips:
 
1. "Always document the total time spent with the patient, the total time spent in counseling/coordination of care and the discussion items related to the service," says the Georgia Chapter of the American Academy of Pediatrics. You can do this by documenting:
 
• T (total time spent with the patient) = # minutes
 
• C (counseling/coordination of care total time) =# minutes
 
• Counseled regarding: (the counseling topics).

2. Put a large "T" at the top of the chart. That way if an insurer downcodes an E/M service, staff can easily identify that the pediatrician coded the visit based on time.

How it works: A newly relocated mother comes to you to discuss behavior problems and possible substance abuse, which is causing her great concern with her adolescent (whom you have never seen). You spend a total of 20 minutes with the mother -- five minutes on history and medical decision-making, and the remaining 15 minutes on counseling.
 
Because counseling comprises the majority of face-to-face physician/family time, you may use time as the controlling factor in selecting the appropriate level of E/M service: 99202 (average time is 20 minutes). Although the encounter did not meet 99202's key components -- the child was absent, so you could not perform an exam -- you may still report a new patient office visit based on time.
 
Don't forget: Your documentation should include the total time spent at the visit (20 minutes), the total time spent counseling (15) minutes, and a summary of your discussion items. Shortcut: Because you are coding the visit based on time, you record:
 
• T = 20 minutes
 
• C = 15 minutes
 
• Counseled regarding: skipping school, lying, sleeping late.
 
At the top of the page, you alert staff that you selected 99202 using time as the key factor with a large "T" in a circle. If the insurer denies the claim, send a form letter stating the pediatrician spent 15 out of 20 total visit minutes on counseling/coordination of care, Jackson says.