Pulmonology Coding Alert

Reader Questions:

99214: Take into Account Discussion with Patient

Question: As a pulmonologist and sleep specialist, I spend a lot of time discussing management, CT scan results, sleep studies, and management of sleep disorders. Most of these are time-based. How do we do that best? Wisconsin SubscriberAnswer: When a physician spends more than 50 percent of total visit time (face-to-face in the outpatient setting, or on the inpatient unit/floor after a face-to-face patient encounter), he can bill based on time instead of the key components (history, exam, and medical decision making). The patient should be involved in the discussion. Document the details of the discussion as well as the time. For example, "25 minutes spent with the patient discussing CT scan results, sleep studies, and management of sleep disorders." Fill in the remaining details, as appropriate. Report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these [...]
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in Revenue Cycle Insider
  • 6 annual AAPC-approved CEUs
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more

Other Articles in this issue of

Pulmonology Coding Alert

View All