Primary Care Coding Alert

Question: A new patient with juvenile diabetes meets with the FP for management of her condition. One of our nonphysician practitioners (NPPs) provides the E/M for the patient, which lasts 37 minutes. Notes indicate that the NPP performed an expanded problem-focused history and exam and straightforward medical decision making, and that she spent 22 minutes advising the patient on proper diet, how to check her own blood sugar, and medication management. Is this an instance where I can code based on total encounter time?

Montana Subscriber

Answer: You may be able to code this encounter based on counseling/coordination of care time; be sure to double-check the total session time and the amount the NPP spent counseling before coding.

If the NPP did spend at least half of the total session time counseling the patient, then report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity & Physicians typically spend 30 minutes face-to-face with the patient and/or family) for the encounter, based on the total time the NPP spent face-to-face with the patient, with 250.01 (Diabetes mellitus without mention of complication; type I [juvenile type], not stated as uncontrolled) appended to represent the patients condition.

Dont stop there: Whenever you invoke the counseling exception for E/Ms, be sure the patients medical record has good documentation of the session. For instance, a good note for your scenario might read: Spent total of 37 minutes with patient. 22 minutes spent counseling patient on her diabetes management, eating habits, and treatment options.

Remember: If you cannot enact the counseling exception for this encounter and code based on time, you must code based on the key elements. Choose the service level using the documented level of history, examination, and medical decision making the NPP provides. In your case, the visits key components would qualify as 99202 (& an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making ...).