Primary Care Coding Alert

When it comes to receiving adequate reimbursement for counseling a patient and/or a member of a patients family, its not cut-and-dry. Mainly because there are no specific codes for counseling. Instead, high-level Evaluation and Management (E/M) codes are appropriate, says Linda Brewer, CPC, MSO-specialty coding, University of Alabama at Birmingham, Health Services Foundation, and a member of the American Academy of Professional Coders Advisory Board. If you can document counseling time, then you can justify higher E/M levels of service, she explains.

Counseling is considered one of the seven components used to define the levels of E/M service. History, examination, medical decision-making, coordination of care, nature of presenting problem and time are the six others. And, although counseling is considered an import-ant factor, it is not required at every patient encounter.

Several scenarios below serve to illustrate different options applicable to counseling coding and documentation.

Scenario 1: A 71-year-old woman with Alzheimers is brought by her daughter to the family doctor. They receive counseling about how to deal with the illness and how to administer appropriate medications. The face-to-face encounter takes 40 minutes with at least 50 percent of the time used to counsel the patient and her daughter.

Coding Solution: Brewer recommends coding 99215 (office or other outpatient visit for the evaluation and management of an established patient which requires at least two of these three key components: a comprehensive history, a comprehensive examination and medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family).

CPT 2000 says: When counseling and/or coordination of care dominates (more than 50 percent) the physician/ patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. 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 (e.g. foster parents, persons acting in locum parentis, legal guardian). The extent of the counseling and/or coordination of care must be documented in the medical record.

Peter Catinella, MD, associate professor and vice chairman at the Department of Family and Preventive Medicine at the University of Utah at Salt Lake City, also suggests that coders document thoroughly the length of time of the encounter, what issues were discussed and any relevant details about the history, examination and medical decision-making, if performed.

Scenario 2: A 42-year-old mother of two comes into the family practitioners office with a chief complaint of depression. An established patient, she presents with no other problems but the depression. During the interview, the family doctor uses some counseling techniques to delve into why the patient is feeling as she does. He explores possible stressors, how she is coping or failing to cope with these factors, how she has dealt with stress in the past and her personal relationships. The family doctor provides supporting counseling, including some suggestions for alternative behavior. The total time of the visit is 45 minutes.

Coding Solution: Catinella says this example would also be coded 99215. He recommends that the doctor document the history, report his findings on her mental status derived from the interview (appearance, mood, thought perceptions and attention span), outline neurologic findings such as pupil size, her gaze and gait, detail the issues discussed and present a treatment plan. Although in this scenario the visit was just with the patient, counseling consumed more than 50 percent of the visit.

The key item is documentation, Catinella says. He advises family practitioners to document the time the visit started and finished rather than just providing the total time. The former technique is more objective, while the other more subjective, he adds.

Scenario 3: A 65-year-old male patient is hospitalized with a heart attack. His family doctor meets with the patients wife to counsel her on the risks and benefits of different kinds of treatment, including angioplasty. Although the doctor only spent 20 minutes with the patient prior to seeing the wife, he spent 30 minutes in discussion with her, for a total of 50 minutes.

Coding Solution: If the patient is in the hospital and the family comes into the clinic to talk with the family doctor, that service is usually included in the hospital visit E/M code for that day, says Garnet R. Dunston, CPC, MPC, president/CEO of Dunston Enterprises, a medical practice consulting firm in Phoenix.

In this case, use code 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a detailed interval history, a detailed examination and medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patients hospital floor or unit).

Note: Counseling and/or Risk Factor Reduction Intervention (99401-99429) are used to report services provided to individuals at a separate encounter for the purpose of promoting health and preventing illness or injury. They are not to be used to report counseling and risk factor reduction interventions provided to patients with symptoms or established illness.