If time is documented- based on the requirements- you could report on time. Per
CPT Assistant example...
An example may be helpful to demonstrate how to report physician services when more than 50% of the face-to-face physician/patient encounter is spent in providing counseling and/or coordination of care.
Doctor "A" has been treating Mrs. Smith for type II diabetes, hypertension and obesity for several years. Prior to this appointment, blood work was performed to determine the status of her diabetes. The physician examines the patient for evidence of infection or circulatory problems. He asks the patient about her compliance to the 1200-calorie diet she has been on for the past six months. After reviewing these findings, the physician indicates to the patient that she will have to begin using insulin, since her diabetes is not responding to the current treatment (diet, exercise and oral hypoglycemic agent). The patient immediately begins to sob uncontrollably. She tells the physician this means she is going to die, because her grandmother got gangrene from this kind of diabetes and died from it.
After calming the patient, Doctor "A" discusses insulin dependent diabetes with the patient and explains that using insulin is not a "death sentence;" He discusses diet, insulin administration, hypoglycemic reactions as well as the symptoms of hyperglycemia. He instructs Mrs. Smith in proper foot and skin care - as well as how to regulate her insulin and diet. He also stresses the importance of seeing her ophthalmologist regularly.
After this detailed counseling session on diabetes in general, he tells Mrs. Smith how she specifically will be treated for her insulin dependent diabetes. He tells her what the starting dosage of her long-acting insulin will be and how it will be adjusted according to how her body reacts to the initial dose. She is assured that the starting dose will not make her become "unconscious," as it did her grandmother. Dr. "A" discusses the necessity for frequent blood sugar tests during the adjustment of her insulin dosage.
Mrs. Smith says she feels much calmer now and feels sure she'll learn a lot from the booklets Dr. "A" has given her. Dr. "A" tells her to come back on Friday and his nurse will show her how to administer her insulin.
The total time Dr. "A" spent with Mrs. Smith was forty minutes; thirty minutes of this time were spent counseling. Code 99215 would be reported, based on the total time spent face-to-face by Dr. "A" with Mrs. Smith. Dr. "A's" documentation should indicate the extent of the counseling he provided at this encounter. (
Note: Doctor "A" did not perform two of the three key components required to report code 99215. Because counseling dominated the face-to-face physician/patient encounter, time is considered the controlling factor to qualify for this level of service. Code 99215 was selected because the total time spent with Mrs. Smith (an established patient seen in his office) was 40 minutes.)
Medicare:
C. Selection Of Level Of Evaluation and Management Service Based On Duration Of Coordination Of Care and/or Counseling.--Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.
EXAMPLE: A cancer patient has had all preliminary studies completed and a medical decision to implement chemotherapy. At an office visit the physician discusses the treatment options and subsequent lifestyle effects of treatment the patient may encounter or is experiencing.
The physician need not complete a history and physical examination in order to select the level of service. The time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.
The code selection is based on the total time of the face-to-face encounter or floor time, not just the counseling time. The medical record must be documented in sufficient detail to justify the selection of the specific code if time is the basis for selection of the code.
In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided.
https://www.cms.gov/Transmittals/Downloads/R1810B3.pdf
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