Pediatric Coding Alert

Question: May I use time to select a second E/M code even if the other service code isn't time-based?


Ohio Subscriber


Answer: Yes. You may use time as the key factor for reporting an E/M code appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Catch: Counseling and/or coordination of care must constitute more than 50 percent of the face-to-face time the pediatrician spends addressing the problem. 

Example: A mother brings her 9-year-old son in for an established patient preventive medicine service. During the visit, the mother asks about switching her child from Ritalin to Concerta to control his attention deficit disorder symptoms and requests advice about handling his behavior at home and school.
 
The pediatrician spends 15 minutes performing an ADD-specific expanded problem-focused history, expanded problem-focused examination and low- complexity medical decision-making in which she decides to change the child's prescription. She then counsels the mother on ADD-medication treatment options, follow-up, and home and school discipline issues for 15 minutes.

Even though the problem-related E/M service's key components qualify the visit as a level-three service (99213-25), you can use time as the controlling factor and report 99214-25 (15 exam minutes + 15 counseling minutes = 30 total minutes).

The fact that CPT 99393 (Periodic comprehensive preventive medicine reevaluation and management of an individual ...; late childhood [age 5 through 11 years]) is not a time-based code does not affect your ability to use time when selecting the E/M problem-related code.