Counseling is considered a key component when selecting an evaluation and management code

There are instances when your patient encounters are not driven by the key components of history, examination and medical decision making.  In some cases, it is more relevant to select the level of service based on the time spent with the patient.

The CPT® book states, “When counseling and/or coordination of care dominates (more than 50 percent) the encounter with the patient…then time shall be considered the key or controlling factor to qualify for a particular level of E&M services”.  Your medical record should include the total time spent with the patient and the amount or percentage of the total time that was spent in counseling.

The documentation should be descriptive about the nature of the discussion or education provided.  Some common scenarios for billing based on time are counseling regarding:  prognosis and treatment planning, risks and benefits of management of the condition, importance of compliance with the plan of care, or education and instructions for management of the disease.

Here are some examples of documentation that would satisfy the requirements:

• “We spent more than 50% of our 45 minute visit discussing the prognosis, plan, additional treatment, and the overall outlook for Stage IV non-small cell lung cancer.”
• “I spent 25 minutes with the patient, 20 of which was spent reviewing recommended dietary changes and educating her on carb counting and sliding scale insulin.”

In the office setting, this would be face-to-face time with the patient.  Time spent reviewing records prior to the patient’s visit or speaking with a referring physician to accept a consultation do not count toward the face-to-face time in the office setting (these should be documented, however, as they are a factor in the medical decision making component of the E&M when not billing based on time).  In the hospital setting, both face-to-face time and unit time can be used to calculate the total time spent.  Unit time includes, in addition to the bedside time: reviewing the chart, placing orders for diagnostic studies or ancillary evaluations, and communicating with other medical professionals.  Also specific to in-patient services, discussions with family may count toward the time if it is well documented that the patient is unable to participate in making decisions about his/her care and therefore the family meeting is necessary to decide on treatment plans.

So, if counseling, educating or coordinating care is the overriding reason for the encounter, document the total time spent, the amount spent in discussion, and the nature and content of your conversation.  When supported in the medical record, the time will replace the history, exam and medical decision making as the determining factor for the selection of the level of service.

The times associated with various categories of E&M codes appear below.

Sources:  Current Procedural Coding Expert (AMA); Medicare Claims Processing Manual, Chapter 12

• Use these rules when billing for codes that use the 1995/1997 guidelines. After 2021, this does not include codes 99202–99215. For those codes, see Time: using time for E/M services in 2021
• You can use time to select Evaluation and management codes if typical time is listed for that code in the CPT® book and the visit is predominately counseling and coordination of care. Document the total time of the visit, the fact that more than 50% of the visit was counseling and the nature of the counseling.
• Emergency department visits do not have typical time listed, and time may not be used to select the level of ED visit. Three of the three components (history, exam and MDM) are required.

What codes continue to use 1995/1997 rules?

• Hospital services, 99221–99233
• Consultations, 99241–99255
• Home visits, 99341–99350
• Observation care, 99218–99220, 99224–99226,
• Observation or inpatient hospital care 99234–99236
• Domiciliary care, 99324–99337

Documentation requirements | Using time to select the code

• For time based codes, document time in the medical record, not just the billing record
• Counseling/coordination of care must “dominate” the visit, that is, must be more than 50% of the encounter
• For outpatient consults, home visits and domiciliary care, more than 50% of the face-to-face time must be in counseling or care coordination; for facility visits, more than 50% of the unit time

Counseling is discussion with patient and/or family regarding:

• Diagnostic results, impressions, recommended diagnostic studies
• Prognosis
• Risks & benefits of management
• Instructions for management
• Importance of compliance
• Risk factor reduction
• Patient and family education

Key points when using time to select a CPT® code

• Document time in the medical record when time is used to select the service.
• For E/M services in which time is the determining factor, document the total time of the visit, the fact that more than 50% was spend in counseling, and the nature of the counseling. Select your level of service based on the total time.
• For prolonged services, select the level of E/M code that you provided and documented. If your total time spent with the patient was 30 minutes more than the typical time, you may add on a prolonged services code. Document the total time. use the chart to select the code. If the visit is entirely counseling, select the highest code in that category (if time spent) before adding the prolonged services code.

What to document for codes

See the Definitive Guide to Documenting Time

• Total time for the visit (provider, not staff time)
• Statement that more than 50% of the visit was counseling or coordination of care
• Description of the nature of the counseling

Remember, codes 99202–99215 no longer follow this guidelines.

Citations
Internet Only Manual, Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, Section 30.6.15.1

Prolonged Services

Starting January 1, 2021, 99354 and 99355 may not be reported with codes 99202–99215.

Bill an E/M and prolonged or just an E/M based on time?

• If the visit is 100% counseling, bill an E/M based on time. Add prolonged services only when the threshold time for the highest level of code plus 30 minutes is met
• If the visit has history, exam and MDM components, bill an E/M based on the level of service, and add a prolonged code if the total time is 30 minutes more than the typical time for the code.

Download the Definitive Guide to Using Time to use as a handy quick reference.

[/mepr-show]

Login to read the rest of this article

Don’t have a login? Become a member, or learn more about the benefits of membership by clicking on the link below.

Get Unlimited Access to CodingIntel’s Online Library

Are you a coder, biller, administrator,
office manager or physician?

Learn more about the benefits of
a CodingIntel membership

click here!

Is counseling is considered a key component when selecting an evaluation and management code?

When selecting an evaluation and management code three components are considered?

What are the 3 key components of evaluation and management?

What are the key components of the office and other outpatient evaluation and management coding?