Tip: Time-based E/M might be in line when managing diabetes, asthma, ADHD.
Overlooking time as the key factor on a camp or sports exam in which the patient has a problem could cut $30 per claim.
Opportunity: An office visit (99201-99215, Office or Other Outpatient Services) using time as the key factor might be appropriate, but keep in mind that lowballing time-based E/M codes because of poor documentation can be a revenue-loser for many practices, says Jennifer Godreau, who’s presenting a free webinar next week to help coders tackle trouble-spots.
Watch for Chronic Conditions
“If there is a chronic medical problem to update, e.g. asthma, we often use that diagnosis code (such as 493.00, Extrinsic asthma; unspecified) and code by time, as counseling will often be more than 50 percent of the visit time,” says Marc Tanenbaum, MD, FAAP, a pediatrician with Pediatrics and Adolescent Medicine in Atlanta.
The patient’s health problem might affect his ability to participate in a certain camp activity or type of camp. “I’d want to do a more recent assessment and some updated counseling regarding the patient’s health issue and how to handle any potential problems that might arise at the camp,” notes Nancy Bishoff, MD, FAAP, a private practice pediatrician in Lexington, Ky.
Be Alert to Counseling Time
When coding based on time, careful complete documentation of the time elements is a must, including total face-to-face time, and minutes spent counseling and/or coordinating care. Also include a brief sentence related to the general areas discussed during the time.
Check out how the key components of history, examination, and medical decision making (HEM) versus time measures up in this example: A teenage boy with benign hypertension (401.1, Essential hypertension; benign) wants to attend survival camp. The pediatrician performs an expanded problem focused history, an expanded problem focused examination, and low complexity medical decision making, which qualifies as 99213 based on HEM. The pediatrician documents she spends 15 minutes counseling the patient on hypertension management and the visit lasts 25 minutes.
Because counseling comprises the majority of the encounter’s total face-to-face time, you can code the visit using time as the controlling factor and select 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 … Physicians typically spend 25 minutes face-to-face with the patient and/or family). If you had overlooked this fact and instead coded 99213 based on HEM, you would have sacrificed approximately $31* in pay.
*Note: The 2009 Medicare Physician Fee Schedule, which you can use as a benchmark to judge private payers’ fees, assigns 2.56 relative value units to 99214.
Using the conversion factor of 36.0666, 99214 pays approximately $92. Code 99213 has 1.70 RVUS, which equates to approximately $61.
Heads Up on Other Disorders, Diseases
Some other examples of chronic conditions that might warrant an updated history, exam, and counseling are diabetes (for instance 250.01, Diabetes mellitus without mention of complication; type 1 [juvenile type], not stated as uncontrolled) and ADHD (314.01, Hyperkinetic syndrome of childhood; attention deficit disorder; with hyperactivity).
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