Primary Care Coding Alert

If time-selected E/M documentation does not detail three requirements, you could be faced with writing a huge payback check.

That's the lesson one physician learned. See if you can spot the problem with this chart entry.

Audited note: An 8-year-old boy seen for ADHD (chief complaint) FU (HPI ��" duration) visit. He has been on stimulant medication (HPI ��" modifying factor) for one month (HPI ��" duration) but is not doing well (HPI ��" quality). He is still having problems attending school (social history ��" education) and with off-the-wall behavior at home (HPI ��" severity). His parents have not noted problems with appetite (ROS ��" constitutional) or sleep issues (ROS ��" neurological or respiratory ��" not both). Physical examination consists of a brief neurological examination ([per 1997 guidelines] can't give credit here as there are no details) (problem-focused exam using the 1995 documentation guidelines). Extensive counseling is done for school and behavioral issues, his diagnosis of ADHD, and treatment options (counseling description). His stimulant dosage is increased (prescription drug management ��" table of risk ��" moderate) (MDM risk: 2 pts) and FU planned in one month. Total face-to-face time is 25 minutes (can't use this without knowing how much of that time was spent counseling).

Before using time as the controlling factor, check off the following requirements from Lisa Curtis, CPC-I, CPC-E/M, who specializes in E/M audits in the Greeley, Colorado area. To code based on time, the physician must document:

- the total time spent with the patient

- that more than 50 percent of the face-to-face time the physician spent with the patient or family is counseling or coordination of care. "I advise my providers to state the actual time (for instance, -45 minutes was spent with the patient in total, 30 minutes in counseling-)," Curtis says.

- a description or summary of the counseling or coordination of care.

Problem: Although the documentation in the previous chart indicates the encounter's total face-to-face time (25 minutes), the physician fails to indicate the percentage of the encounter that she spent on counseling or coordination of care. CPT lets you select an office visit code based on time only when the physician spends more than 50 percent of the face-to-face time with the patient or family member on counseling or coordination of care, explains Richard H. Tuck, MD, FAAP, at PrimeCare of Southeastern Ohio in Zanesville. "If documentation does not specify that the encounter has met the more-than-50 percent counseling requirement, you should not use time as the controlling factor to select the level of E/M service."

You instead have to code the visit based on the documented history, examination, and medical decision making, says Suzan Berman-Hvizdash, CPC, CPC-EM, CPC-ED, coding and compliance manager with the UPMC-UPP Department of Surgery in Pittsburgh. Her breakdown of the note linked to the parenthetical chart entry explanations includes:

- HPI ��" quality, severity, duration, modifying factors ��" EXTENDED

- ROS ��" constitutional, neuro (or respiratory ��" not both)

- PFSH ��" social

- Exam ��" NONE (1997 guidelines)

- MDM:
Diagnosis/management options ��" est. problem worsening ��" 2 points
Data ��" NONE
Risk ��" moderate

Using the 1995 guidelines, Kent J. Moore, manager of the Health Care Financing and Delivery Systems for the American Academy of Family Physicians, would also count the exam. "I think you would still get credit for a problem-focused exam, if a brief neurological examination was noted," he points out.

Code: 99213 (history ��" detailed, exam ��" none [1997 guidelines] or problem-focused [1995 guidelines] and MDM low complexity).

Without knowing how much of the 25 minutes the physician spent counseling, the note supports 99213, not 99214 (... a detailed history; a detailed examination; medical decision making of moderate complexity -), Hvizdash says. That's a difference of approximately $30, using the 2008 Medicare Physician Fee Schedule, which assigns 1.68 relative value units (RVUs) to 99213 and 2.53 RVUs to 99214 with a conversion factor of 38.0879.

Solution: Adding the actual time that the physician spent on counseling, such as "15 min. spent counseling on the documented related issues," would indicate that the encounter meets time-based coding's criteria that the physician spend more than 50 percent of the encounter time on counseling or coordination of care.

Warning: If an insurer finds that a sampling of documentation for your higher-level visits falls short of the levels you are selecting, the payer can extrapolate its findings to the rest of your cases for that payer, Tuck says. You could end up having numerous visits downcoded, resulting in a major payback.