Pulmonology Coding Alert

Question: An established patient returned to the office to discuss a finding on a computed tomography (CT) scan of his chest and abdomen that showed a large aortic aneurysm with a right lung lesion and nodules. The pulmonologist reviewed the findings and implications, ordered additional testing and answered the patient's questions. The physician also spoke with the patient's primary-care physician (PCP) before the patient's visit. Although the doctor did not perform an exam, take a history, etc., he spent 35 minutes face-to-face with the patient and 10 minutes talking with the patient's PCP. How should we bill for this?

California Subscriber

Answer: If more than half the time spent with the patient was counseling, you can use the "total visit" time to determine the E/M service level. For example, the total "face-to-face" time during a visit was 45 minutes. During this 45-minute visit, 10 minutes were spent obtaining an interval history and performing a focused exam while the remaining 35 minutes were spent counseling the patient. Since more than 50 percent of the visit was spent counseling/coordinating care, the E/M level can be selected on time, the "total visit" time. Therefore, 99215 is reported for this service.

The scenario outlined in the question suggests that 100 percent of the visit was spent counseling the patient. When this occurs, the "total visit" time is equivalent to the counseling time, i.e., 35 minutes. For a 35-minute visit spent counseling, the service level is synonymous with an established outpatient visit of 35 minutes. In this case, you would use 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of the three components physicians typically spend 25 minutes face-to-face with the patient and/or family). The physician must document specifically what he or she discussed with the patient in addition to the "total visit" time and/or counseling time.

You should not bill for talking to the patient's PCP unless the patient was present during the discussion. If that is the case, you would add this time to the original E/M code. This would make the entire counseling time 45 minutes, and you would bill 99215.