Primary Care Coding Alert

Question: Our family physician saw a patient today for arthritis. She had been to the practice before, but not for this problem. After talking with her for about half an hour, the physician discussed several non-surgical ways she should try to improve her condition (such as changes in diet, lifestyle, exercise, etc.) before she pursued any more serious treatment. Since he didn't examine her, how should we bill for this?

Texas Subscriber

Answer: Because counseling comprised more than 50 percent of the physician's time with the patient, you can base the level of service on the amount of time that the physician spent with the patient. (Remember, CPT states, "If counseling or coordination of care dominates [more than 50 percent] the physician/patient and/or family encounter, then time may be considered the key or controlling factor to qualify for a particular level of E/M service.")

For instance, if the FP spent 30 minutes with her, of which he spent only 10  minutes documenting her history and test results, and he spent the remaining 20 minutes counseling her, the FP can legitimately bill 99214 (Office or other outpatient visit for the evaluation and management of an established patient ... physicians typically spend 25 minutes face-to-face with the patient and/or family).

The FP must perform such a visit face-to-face, as opposed to a discussion with the patient over the phone.

- Reader Questions and You Be the Coder were reviewed by Kent J. Moore, healthcare financing and delivery systems manager at the American Academy of Family Physicians; and Daniel Fick, MD, assistant dean for clinical affairs at Carver College of Medicine and senior assistant hospital director at University of Iowa Hospitals and Clinics in Iowa City.