Practice Management Alert

Test your billing knowledge by determining how you would solve the two real-life billing problems below. When you're finished, turn to page 37 for the solution from our experts.
 
Problem #1: The physician diagnosed a child with a high lead toxicity level. The physician took 30 minutes to make the diagnosis and an additional 45 minutes counseling the parents on how to guard against further lead exposure. The biller submitted 99213 for the established patient visit, then appended modifier -25 (Separately identifiable service) and charged 99403 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 45 minutes) for the counseling service. The patient's carrier paid 99213 but denied 99403.

Problem #2: A 19-year-old patient presented for an annual physical and was diagnosed with bronchitis caused by smoking. In addition to the time he spent performing the annual physical, the physician documented a separate 15-minute service to diagnose the bronchitis and an additional 40 minutes counseling the patient on how to quit smoking. The biller reported the preventive medicine physical with 99395 (Preventive medicine service; 18-39 years) and the bronchitis treatment with 99213 (Established patient evaluation and management service). The biller reported 99402 (... approximately 30 minutes) for the smoking-cessation counseling. The patient's carrier denied the 99402 but paid the two other services.

Answer: Counseling and/or risk factor reduction intervention codes 99401-99429 "are used to report services provided to individuals at a separate encounter," according to CPT. In both billing problems on the front page, the physicians performed an E/M visit, "so those counseling codes cannot be used," says Catherine Brink, CMM, CPC, president of HealthCare Resource Management Inc. in Spring Lake, N.J.

Billing Options

1. Bill by time: When counseling dominates more than 50 percent of the physician encounter, "then time may be considered the key or controlling factor to qualify for a particular level of E/M services," CPT states. So, if you would normally bill 99213 for a visit, but the physician spent 40 extra minutes counseling, you can report 99215 (which includes 40 minutes of face-to-face patient time) to recoup for the physician's counseling time.

The drawback: If your physician spends more than 40 minutes counseling an established patient, or 60 minutes counseling a new patient, even a level- five E/M code may not account for the entire length of service.

2. Use prolonged service codes: Prolonged service codes (99354-99357) describe extended physician service times above and beyond the time included in the E/M code as outlined by CPT. These codes describe face-to-face patient encounters, but the service does not have to be continuous. So, if your physician renders an E/M service and then an additional 45 minutes of counseling, you can report the E/M code and then +99354 (Prolonged physician service; first hour) to account for the extra time. For more on billing prolonged service codes, see "May's Recipe for Billing Success".

Careful: Payers will often reimburse these codes but may ask for documentation first. Before billing, make sure your physician records the start and stop time of all face-to-face patient contacts and documents a synopsis of the counseling or other extended service, Brink says.

3. Have the patient come back for a separate counseling session. In this case, you can use 99401-99429. This may be a good option for smoking cessation counseling or other medical problems, such as diabetes. Check with your carriers first to see if they'll pay for counseling codes.