Pediatric Coding Alert

Remember to always document visit times when coding based on the clock.

Picture this: A pediatrician provides an E/M service for an established patient that requires an expanded problem-focused history and exam. The E/M encounter, however, takes nearly 45 minutes to complete because the doctor spends so much time educating the patient. How would you report this E/M service?

Opportunity: If the visit meets the correct counseling/coordination of care parameters, you should report the visit using time as the controlling factor rather than the standard three key components.

Keep in mind: CPT notes that "this includes time spent with parties who have assumed responsibility for the care of the patient or decision-making, whether or not they are family members (eg, foster parents, person acting in loco parentis, legal guardian."

But how you select the right code may boil down to the fine print in CPT 2011. According to this year's CPT manual, you can use the code closest to the documented time. "If coding by time, pick the closest typical time," said Peter Hollmann, MD, during the "E/M, Vaccines, and Time-Based Codes" session at the CPT and RBRVS 2011 Annual Symposium in Chicago this past fall.

That advice echoes previous AMA information. For instance, the August 2004 CPT Assistant stated, "In selecting time, the physician must have spent a time closest to the code selected."

Your documented time must equal or exceed the average time given to bill that level. For a 35 minute visit spent on a medically necessary counseling-dominated visit, per CPT you could report 99215.

Some Payers May Opt for CMS Guidelines

Keep in mind that although the AMA, via CPT Assistant, directs you to code based on the "closest" time, most Medicare payers have always considered the times indicated in CPT's code descriptors to represent minimums. Under those regulations, the physician would select the lower code (for instance 99214, ... physician typically spends 25 minutes face-to-face with the patient and/or family ...) unless the time was greater than or equal to the higher-level code's required time (such as 40 minutes for 99215). Many Medicaid payers and some private insurers follow Medicare's lead rather than CPT's, which can lead to confusion at your pediatric practice.

CPT 2011 restates the type of time that should be counted toward time-based counseling, noting that you "shall" use time based coding when the counseling and or coordination of care dominates or comprises more than 50 percent of the encounter's time. You should ideally document the start and end time of the counseling/coordination of care, as well as the total visit time, in your notes. It's better to have this written by the physician, rather than just from an EMR time stamp, because without seeing how a system's time stamp works, it's hard to say if the "start" time indicates the time the face-to-face encounter began or the time that the patient came into the room.

The advantage of coding based on your visit's proximity to typical times will be that pediatricians may benefit from reporting E/M higher levels. "Traditionally among pediatricians, time is under-utilized," says Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville. "We, as cognitive physicians, can now get paid as much for using our time-based cognitive skills as we do for our procedural skills."

Plus: Stay on Top of Prolonged Service Coding

Another common pediatric coding conundrum comes into play when you're considering prolonged service codes 99358-99359 for your E/M services. Keep in mind that you've been able to count indirect prolonged service time that occurs around the date of the E/M service ever since 2010. Under the old definition from 2009 and before, the non-face-to-face service had to be the day of the E/M visit. However, since Jan. 1, 2010, you simply have to prove that the time was "related" to the E/M service.

Be careful: Prolonged service codes 99358 (Prolonged evaluation and management service before and/or after direct [face-to-face] patient care; first hour) and +99359 (... each additional 30 minutes [List separately in addition to code for prolonged physician service]) still have to relate to an E/M service that involves patient contact. The prolonged service "must relate to a service or patient where direct [face-to-face] patient care has occurred or will occur and relate to ongoing patient management," according to the revised notes. CPT places no timeframe on the time that can elapse between the primary service and the prolonged before and/or after direct patient care service.

"The loosening of the prolonged non-face-to-face service codes has been a great help if you're seeing a complex child," Tuck says. You can review the patient's chart and make phone calls before and after seeing the patient and count that time. Remember that you need a minimum of 30 minutes to bill the first hour of prolonged non-face-to-face care.

Keep in mind: If your practice uses electronic billing, you may miss the opportunity to add "related" prolonged service times to your claims. "With electronic billing, the encounter is sent straight to the front office and the bill is sent out immediately," Tuck says. "So you have to work with the practice management staff to ensure that you're holding the claim until all of the extra work related to that E/M visit is completed and documented," he advises.

For example: You're seeing a new patient premature infant graduate of the neonatal intensive care nursery. The infant has had a stormy newborn course and has extensive records to review. A home health care agency is involved caring for the newborn for his multiple problems. The pediatrician reviews the records the day prior to seeing the infant, and calls the home health care agency the day following the visit. Total non-face-to-face time spent on this work is 30 minutes. The correct coding is 99205, +99358, linked to a diagnosis of prematurity (765.10). No modifier is required to use the prolonged services codes.