Primary Care Coding Alert

Question: What code is best to use for family counseling for a dying patient?

Arizona Subscriber

Answer: Generally speaking, you would assign the appropriate evaluation and management (E/M) code.
According to CPT, counseling includes a discussion with the patient and/or family concerning one or more of the following:

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; and

patient and family education.

It is not normally recommended to record time unless you routinely meet or exceed documentation guidelines (it could be used against you in an audit).

There is an exception, however: CPT provides a billing opportunity when the physician (not staff) spends considerable time counseling. 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 for a particular level of E/M services. You should document total time and describe the counseling and/or activities to coordinate care. Choose the appropriate E/M code that meets the time requirements that CPT outlines.

Answered by Tammy Chidester, CPC, billing supervisor, Upshur Medical Management Services Inc., in Buckhannon, W.Va.