Primary Care Coding Alert

Counseling, established patients get you an encounter faster

If you report an office visit only when your family physician documents a history, examination and medical decision-making, you could be missing reimbursement that you deserve.

You can throw the "all of the key components" rule out the window in two instances: established patient office visits and counseling-dominated encounters. To improve your reimbursement, experts reveal the essentials of E/M service coding:

Search for HEM With New Patient Visits, Consults

To bill 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient) or 99241-99245 (Outpatient consultations), your FP must base the visit's level on all three key components. That means that he must take a history, perform an examination and provide medical decision-making.

Tip: Select the appropriate new patient office visit level or consultation level based on the lowest E/M component. "The history, exam and medical decision-making need to be at the same level or higher to support the level of care," says Teresa M. Thompson, CPC, CCC, a coding specialist and the owner of TM Consulting, a national medical consulting and management firm in Sequim, Wash.

Example: A school nurse requests your FP's opinion on a 15-year-old male with failing grades and suspected drug use. The physician takes a detailed history, performs an expanded problem-focused examination and uses straightforward decision-making. For the outpatient consultation, you should report 99242 (Office consultation for a new or established patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making) based on the lowest component(s), the exam and decision-making, which are at the same level.

Look for 2 out of 3 for 99212-99215

Supporting a higher-level service is easier with established patient office visit codes (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...). You need only two of the key components to substantiate 99212-99215.

Watch out: You may accidentally downcode if you select the established patient office visit code based on three out of three components. Each of the established patient E/M codes states, "Office or other outpatient visit ... which requires two of these three key components," according to CPT.

Right way: Look for the two highest or same-level components. For instance, an allergic rhinitis patient presents for a follow-up exam and also complains of ear pain. The FP's nurse takes a detailed history. The physician reviews her notes and performs a problem-focused exam with low-complexity medical decision-making.

Based on the two highest components, the history and medical decision-making, you should report 99213 (... an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity).

Pitfall: If you coded the above encounter using the three-out-of-three-components rule, you'd report 99212 (... a problem-focused history, problem-focused examination, straightforward medical decision-making) based on the lowest component, an error that would cut roughly $15 from the claim.

Use Time for Counseling-Dominated Visits

When counseling or coordination of care is the controlling factor, you don't need any components to determine the visit's level.

You should simply select the appropriate E/M code based on the time the FP spent providing the encounter, Thompson says.

You can use time as the key factor as long as counseling and/or coordination of care dominates the encounter. Consequently, your FP must spend more than 50 percent of his time counseling the patient.

"The amount of time is the time counseling and coordinating care for a problem," says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. "That is, time spent discussing what should be done to address the problem, and does not include time for lengthy exams or taking lengthy histories."

Be careful: Documentation must clearly show that counseling and/or coordination of care dominated the encounter. Billing by time often drives the E/M level up much higher. Therefore, payers may challenge the selected code or even downcode the visit based on medical necessity.

Solution: Make sure the physician's notes show how much total time the FP spent with the patient, how much time he spent counseling the patient or coordinating the patient's care, and what he discussed. A short abbreviation, T/C (total time/counseling and/or care coordination time), followed by the counseling and/or care topic, can easily document this crucial information.

For instance, the FP might note: "45T/30C, discussed diet options to control diabetes." The notation indicates that the FP spent a total (T) of 45 minutes on the visit with 30 counseling (C) minutes addressing the patient's treatment.

In this case, because counseling dominates the encounter, you should report 99215 (... a comprehensive history, a comprehensive examination, medical decision- making of high complexity) for the visit's total 45 minutes. The total time the physician spent with the patient exceeds the 40 minutes typically associated with 99215. Therefore, the documentation will clearly support billing the higher-level E/M even if the history, examination and medical decision-making support only a level-three visit (99213).