Pediatric Coding Alert

Interpretive services can stack up to a higher E/M level

When a language barrier causes an office visit to take longer than usual, you can get credit for the extra work using two methods -- one of which may not be too obvious.

An unfunded federal regulation's mandate requires us to provide foreign-language interpreters to non-English- speaking patients, says William H. Cotton, MD, medical director of the Primary Care Network at Columbus Children's Hospital in Ohio. Interactions that involve a foreign-language interpreter to provide care take longer and are more complicated than regular interactions, he says.
 

Good news: The additional work of using an interpreter allows you to code for a higher level of care. Test your familiarity with complex E/M coding with the following case study.

Review OM Case Involving Increased Effort

 A 5-year-old boy from a Spanish-speaking family comes in for evaluation of fever and ear pain. Normally you would code this as an established patient level-three visit with a diagnosis of otitis media (OM) and treatment with antibiotics, Cotton says.
 The problem: Because the pediatrician requires an interpreter to communicate with the patient and parent, the encounter takes 10 minutes more than the physician would typically spend on a similar visit that didn't require an interpreter. How should you code the interaction to receive credit for the increased effort?

Realize Interpretive Code Isn't an Option

 Unfortunately, you can't use an exact CPT code to represent the extra work. "No specific codes exist for providing and using foreign-language interpreters," says Richard H. Tuck, MD, FAAP, a nationally recognized speaker on pediatric coding and pediatrician at PrimeCare of Southeastern Ohio.
 Workaround: You can, however, capture the increased work through E/M services. "The additional work of using an interpreter allows you to code at higher levels," Tuck says. You could justify a level-four visit from two perspectives.

Method 1: Use Time to Bump Up the Level

 Did you first jump to time-based billing to capture the added work of using an interpreter? Additional time spent counseling and coordinating care could support billing 99214 (... physicians typically spend 25 minutes face-to-face with the patient and/or family) instead of 99213 (... physicians typically spend 15 minutes on this service). You would need to spend more than 50 percent of the encounter for counseling and interpretation, including the interpreter/translation time.
 Example: Assuming the total visit time is 25 minutes or more, Tuck says, the breakdown would include the:
 • 10 minutes for the interpreter
 • additional 3 to 5 minutes of counseling and coordinating care in the other 15-minute segment.

 Counseling and coordinating care dominates the visit (13-15 minutes of counseling time out of 25 minutes of total time), so you would use time-based billing to justify a level-four visit.

Method 2: Factor Family Issues in Hx, MDM

 The less obvious way that the interpretive service encounter could add up to 99214 is by using history (hx) and medical decision-making (MDM) elements to support a higher level of service. A 99213 requires two of these three components: an expanded problem-focused hx, an expanded problem-focused examination, and MDM of low complexity. Code 99214 requires two of these three key components: a detailed hx, a detailed examination, and MDM of moderate complexity. Although the examination level remains the same regardless of language barrier, it could raise the:
 • hx from an expanded problem-focused to a detailed
 • the MDM level from low to moderate complexity.

 Do this: Look for pertinent past, family, and/or social hx directly related to the patient's problems to boost the hx type. "With an interpreter, in addition to time, the history will typically require additional questions related to cultural and family issues," Tuck says.
 Consider raising the data-complexity element based on documentation that shows how using the interpreter made obtaining information more difficult. "The medical decision-making would likely also be more complex related to the same cultural, family and language issues," Tuck says.
 In fact, the Marshfield Clinic's audit worksheet awards two points under the Amount and/or Complexity of Medical Records Reviewed for "review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another healthcare provider" and one point for the "decision to obtain old records and/or obtain history from someone other than patient." The case study without the interpreter could include these MDM elements:
 • number of diagnoses: limited
 • amount and/or complexity of data to be reviewed: limited
 • risk of complication and/or morbidity or mortality: moderate (for prescription)

 These elements would equal MDM of low complexity. "To qualify for a given type of decision-making, two of the three elements in table 2 (page 8 of CPT 2007) must be met or exceeded," according to the E/M Services Guidelines. If the interpretive services raise the data- review element from "limited" to "moderate," two of the elements would be at the "moderate" level, making the type of decision-making moderate, which along with a detailed history supports a level-four visit.
 Bottom line: "This additional history and medical decision-making could justify a 99214 without the time element consideration," Tuck says.