When Counseling Dominates, Cpt Allows You To Select Code Based On 'closest Typical Time'

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Here’s a pediatric coding scenario: A pediatrician provides an evaluation & management service for an established patient that calls for an expanded problem-focused history and exam. However the evaluation & management encounter takes nearly 45 minutes to complete since the doctor spends so much time teaching the patient. How would you report this evaluation & management service?


Opportunity: If the visit meets the proper counseling/coordination of care parameters, you should report the visit using time as the controlling factor rather than the standard three key components.


Remember: CPT notes that this includes time spent with parties who have taken responsibility for the care of the patient or decision-making, whether or not they are family members (example foster parents, person acting in loco parentis, legal guardian.")


However how you choose the right code may boil down to the fine print in CPT 2011. As per 2011 CPT manual, you can use the code closest to the documented time. If you are coding by time, choose the nearest typical time. ...
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This advice echoes previous AMA information. For example, the August 2004 CPT Assistant read, “In selecting time, the doctor must have spent a time closest to the code chosen."


Your documentation time must be equal or more than the average time provided to bill that level. For a 35-minute visit spent on a medically necessary counseling-dominated visit, CPT advises you to report 99215.


Some payers may go for CMS guidelines


Remember that even though the AMA, through CPT Assistant , directs you to code based on the 'closest'time, most Medicare payers have always thought about the times indicated in CPT’s code descriptors to represent minimums. Under those regulations, the doctor would choose the lower code unless the time was greater than or equal to the higher-level code’s required time (say for instance 40 minutes for 99215). Many Medicaid payers as well as some private payers follow Medicare’s lead rather than CPT’s, which can go on to create confusion at your pediatric practice.


CPT 2011 restates the kind of time you should be counted toward time-based counseling, noting that you 'shall'use time based coding and coordination of care dominates or comprises more than 50 percent of the encounter’s time.


Ideally in your notes, you should document the beginning and start time of the counseling/coordination of care as well as the total visit time. It is better to have this written by the doctor rather than just from an EMR time stamp since without seeing how a system’s time stamp functions, it is difficult to say if the 'start'time indicates the time the face-to-face encounter began or the time that the patient stepped into the room.


The benefit of coding based on your visit’s proximity to typical times will be that pediatricians may benefit from reporting Evaluation/Management higher levels. Traditionally among pediatricians, time is under-utilized. Cognitive physicians can now get paid as much for making use of their time-based cognitive skills as they do for their procedural skills. In addition: Stay on top of prolonged service coding


One more common pediatric coding conundrum comes into play when you are thinking about prolonged service codes 99358-99359 for your Evaluation & Management services. Remember that you have been able to count indirect prolonged service time that occurs around the date of the evaluation & management service ever since last year. Under the old definition from 2009, and before, the non-face-to-face service had to be the day of the evaluation & management visit. But then since January 1 last year, you simply have to prove that time was related to the evaluation & management service.


Word of caution: Prolonged service codes 99358 and +99359 still have to relate to an evaluation & management service that involves patient contact. The prolonged service must relate to a service or patient where direct patient care has occurred or will occur and relate to ongoing patient management. CPT places no time frame on the time that can elapse between the primary service and the prolonged before and/or after direct patient care service.


The loosening of the prolonged non-face-to-face service codes has been a great help if you are seeing a complex child. You can review the patient’s chart and make phone calls before and after seeing the patient and count that time. Remember that you need a minimum of 30 minutes to bill the first hour of prolonged non-face-to-face care.


Remember: if your practice makes use of electronic billing, you may miss the opportunity to add 'related'prolonged service times to your claims. With electronic billing, the encounter is sent straight to the front office and the bill is sent out right away. As such you have to work with the practice management staff to see to it that you are holding the claim until all of the extra work related to that evaluation & management visit is completed and documented.


For more on this and for other specialty-specific articles to assist your pediatric coding, sign up for a good medical coding resource like Coding Institute.