Counseling representing more than 50 percent of E/M visit? Choose level based on time.
Question: I have a family physician who documented 60 minutes on an established patient’s office visit. The FP diagnosed the patient with morbid obesity (278.01). Since the patient was newly diagnosed and had some difficulty understanding the doctor’s orders, the FP spent more than half the office visit time on counseling on therapeutic lifestyle changes and the treatment regimen. Should I code this as 99214 for the first 25 minutes and +99354 for the remaining time?
Answer: No, since counseling and/or coordination of care takes up the majority of this office visit’s time (counseling represents more than 50 percent of the total time with the patient), choose the level of E/M service based on time. You can assign prolonged services for any remaining established patient office visit time only when assigning 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity … Physicians typically spend 40 minutes face-toface with the patient and/or family). “In those evaluation and management services in which the code level is selected based on time, prolonged services may only be reported with the highest code level in that family of codes as the companion code,” according to the Medicare Claims Processing Manual, Chapter 12, Section 30.6.15.1, “Prolonged Services with Direct Face-to-Face Patient Contact Service.”
You can capture only the 40 minutes of your encounter. CPT associates 40 minutes as 99215’s typical/average time.
Therefore, use the highest level office visit code: 99215. You lose the additional 20 minutes. Since the FP in this encounter spends only an additional 20 minutes on this encounter beyond 99215’s typical time, the encounter does not meet prolonged service code +99354’s “threshold” time of thirty minutes. You don’t need to report a prolonged service code in this situation.
CMS does not allow you to game the system by adding prolonged services onto a lower level office visit code for more relative value units (RVUs). Since in your scenario, the E/M service code level will be based on time, selecting the following codes will not be appropriate:
• 99214 — Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family)
• +99354 — Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient evaluation and management service).
Refer to the Medicare Claims Process Manual’s Chapter 12 here.
@ Family Practice Coding Alert
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