Primary Care Coding Alert

You can boost your E/M levels and generate more reimbursement for your practice by tracking patient counseling and coordination-of-care time during an office visit - if you know the ropes for reporting E/M services based on time.
 
According to CPT, when counseling and/or coordination of care takes up more than 50 percent of the physician's face-to-face time with the patient, time becomes the determining factor when choosing a particular E/M service level. The content of the counseling and/or coordination of care - what the family practitioner (FP) talked about with the patient - must be documented in the medical record, CPT states.
 
The AMA defines counseling as a "discussion with a patient and/or family concerning one or more of the following areas":

  Diagnostic results, impressions and/or recommended diagnostic studies
  Prognosis
  Risks and benefits of management (treatment) options
  Instructions for management (treatment) and/or follow-up
  Importance of compliance with chosen management (treatment) options
  Risk factor reduction
  Patient and family education. Counseling time also includes time spent with the parties who have assumed responsibility for the patient's care or decision-making. But Medicare and most insurance companies do not pay for family education without the patient present. If, for example, a family member wants to talk to a doctor concerning a patient's diabetes and the risk it poses to the patient's eye health (250.5x, Diabetes with ophthalmic manifestations), Medicare requires the patient to be present in the room with the family member for it to reimburse for the visit. 1. Determine How the Documentation Measures Up "The physician should document the total visit time and how much of that time was spent counseling/coordinating care," says Carol Pohlig, BSN, RN, CPC, reimbursement analyst for the department of medicine at the University of Pennsylvania in Philadelphia. "The physician should also comment on the important issues discussed with the patient in addition to any relevant clinical information, such as the patient's response."
 
Don't forget that only the physician's time spent counseling the patient can be counted toward counseling/coordination of care time. Time spent by the physician's staff on the patient's case is not reportable. Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. of Lansdale, Pa., recommends the following test for compliant documentation when billing based on time:
 
1. Does the documentation reveal the total face-to-face  time in the outpatient setting or on the unit/floor in the  inpatient setting?
 
2. Does the documentation describe the content of the   counseling or coordination of care?
 
3. Does the documentation reveal that the physician    spent more than half of the time counseling or coordi-  nating care? If all of the answers are "Yes," you should specify total encounter time (in minutes). Some insurance carriers ask for specific documentation that shows the time the counseling began and ended, so a best practice for [...]