Pulmonology Coding Alert

You can boost your E/M levels and generate more reimbursement for your practice by tracking patient counseling and coordination-of-care time during an office visit - if you know the ropes for reporting E/M services based on time.
 
Pulmonologists often manage a patient's care for chronic conditions that involve several treatment options and require ongoing attention, such as chronic obstructive pulmonary disease (COPD, 496). These conditions often require a lot of counseling and coordination of care.
 
According to CPT, when counseling and/or coordination of care takes up more than 50 percent of the physician's face-to-face time with the patient, time becomes the determining factor when choosing a particular E/M service level. The content of the counseling and/or coordination of care - what the physician talked about with the patient - must be documented in the medical record, CPT states.
 
The AMA defines counseling as a "discussion with a patient and/or family concerning one or more of the following areas":
   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
   patient and family education. Counseling time also includes time spent with the parties who have assumed responsibility for the patient's care or decision-making. But Medicare and most insurance companies do not pay for family education without the patient present. If, for example, a family member wants to talk to a pulmonary physician concerning a patient's COPD and the risk it poses, Medicare requires the patient to be present in the room with the family member for it to reimburse for the visit. 1. Determine How the Documentation Measures Up "The physician should document the total visit time and how much of that time was spent counseling/coordinating care," says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist for the department of medicine at the University of Pennsylvania in Philadelphia. "The physician should also comment on the important issues discussed with the patient in addition to any relevant clinical information, such as the patient's response."
 
Don't forget that only the physician's time spent counseling the patient can be counted toward counseling/coordination-of-care time. Time spent by the pulmonologist's staff on the patient's case is not reportable. Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. of Lansdale, Pa., recommends the following test for compliant documentation when billing based on time:

 1. Does the documentation reveal the total face-to-face time in the outpatient setting or on the unit/floor in the inpatient setting?
 2. Does the documentation describe the content of the counseling or coordination of care?
 3. Does the documentation reveal that the physician spent more than half of the time counseling or coordinating [...]