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Radiology Coding Alert

Dont Let Your Lengthy E/M Visits Go Underpaid

Published on Tue Jul 01, 2003

The next time your radiologist spends extra time reassuring and counseling a patient in the office, remember: Time rather than the key E/M components of history, exam and medical decision-making (MDM) can be the determining factor when choosing an E/M service level. If you abide by this rule, you may be able to report a higher-level code than the key components alone would warrant.

Step 1: Know the Requirements
 
According to CPT guidelines , when counseling or coordination of care dominates the physician/patient encounter, that is, it comprises more than 50 percent of the visit, "time may be considered the key or controlling factor to qualify for a particular level of E/M services." 
 
The January 1998 CPT Assistant explains further: "Counseling and coordination of care may include discussing one or more of the following areas with the patient: diagnostic results, impressions and/or recommended diagnostic studies, prognosis, risks and benefits of treatment options, instructions for treatment and/or follow-up, importance of compliance with chosen treatment options, risk factor reduction, and patient/family education."
 
Let's apply this principle to CPT's example of a standard interventional radiology E/M service: "Follow-up office visit for a 55-year-old male, two months after iliac angioplasty with new onset of contralateral extremity claudication." (Based on standard documentation for this type of encounter, CPT suggests that the visit might fall into the level-four, 99214, category.)
 
Suppose the patient is anxious and extremely concerned about the possibility of a blood clot. The interventionist spends 75 minutes discussing the patient's progress following the angioplasty, the patient's current symptoms, possible diagnostic tests required, potential treatment options, and preventive measures to alleviate discomfort. Because counseling and coordination of care dominated the encounter, you can use time as the controlling factor when assigning the E/M service level.

Step 2: Consult Standard E/M Times
 
To determine the appropriate E/M level for the time spent with the patient, you should check the reference time included in the CPT descriptor for each code, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center based in Absecon, N.J. For instance, the descriptor for 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...) states, "Physicians typically spend 25 minutes face-to-face with the patient and/or family." 
 
Remember that to qualify as a given E/M level based on time, the physician must spend at least half the total time (which should meet or exceed the reference time of the chosen code) on counseling or coordination of care.  Therefore, if the interventional radiologist documents spending 55 of our example's 75 minutes on counseling, he or she may upgrade the visit to a 99215. 
 
Counseling time also includes time that the physician spends with the parties who have assumed responsibility for the patient's care or decision-making. But Medicare and many private carriers do not pay for family education if the patient is not present. For example, if a family member wants to talk to a radiation oncologist concerning a patient's upcoming brachytherapy course, Medicare requires the patient to be present in the room with the family member.
 
Note: Time spent taking the patient's history or performing an examination does not count as counseling time. The physician must look at the entire patient encounter and decide if he or she spent the majority of time in counseling and coordination of care or if the key components of history, exam and MDM should be the deciding factor when choosing an E/M level.

Step 3: Document Your Work

Documentation is always crucial for time-based E/M services. More important, the physician should specifically note start and stop times for the patient visit, as well as the portion of the time spent on counseling and coordination of care, Jandroep says. CMS guidelines require physicians to document exact times, and practices may have trouble following an audit if they have not noted this information.
 
Physicians should also document what specific issues they discussed in counseling (such as treatment options, prognoses, etc.). For example, the physician might note, "40 minutes with patient discussing the role of exercise during his recovery from prior surgery, possible ways to alleviate pain from claudication, and potential risk signs." It is essential that the nature, severity and quantity of the issues discussed with the patient adequately account for the counseling time recorded.
 
The radiologist should also include the components of history, exam and MDM in the documentation. Good medical recordkeeping requires you to document relevant and pertinent information, even when you use time as the determining factor to choose an E/M level.
 
Step 4: Test Yourself

To ensure that you can ethically report your E/M visit based on the time your physician spends counseling a patient, take this self-test, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. of Lansdale, Pa.:
 
1. Does the documentation show 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 indicate that the physician spent more than half of the time counseling or coordinating care?

If all of the answers are "Yes," you should feel confident basing your E/M level selection on the time spent counseling the patient.
 
It is critical to note that such extensive patient counseling and coordination of care visits should not become a routine for your practice, because E/M visits based on time will never be "the norm" for interventional radiologists only the exception.
 
In addition to meticulous documentation, you should differentiate between standard visits and such extensive visits in your records. And remember that time you spend on the phone with the patient does not count toward the time that dictates the E/M level you should only count the face-to-face time that you spend with the patient.

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