Q When a physician spends more than 50% of an in-office visit counseling and/or coordinating care, we select the appropriate E/M services code based on the amount of time spent counseling, not the total-visit time. How are the 2 different? And does the latter include only physician/patient interactions or can it include the time spent with nurses, medical assistants, etc.?
A Think of the criteria for selecting an E/M code based on time as consisting of 2 factors. First, the counseling time must represent more than 50% of the face-to-face time. Second, if the first condition is met, select the code based on the total face-to-face time documented in the patient’s medical record. This total-visit time is reflected in the nomenclature of each E/M code as follows: “physicians typically spend XX minutes face-to-face with the patient and/or family.”
When documenting the amount of time, record both the total time spent face-to-face with the patient and the amount of time spent counseling the patient. If you only did counseling, i.e., no exam, indicate this in the documentation and record only the face-to-face counseling time. For example, if the total-visit time was 25 minutes and the physician documented that 15 minutes was spent counseling (which meets the 50% requirement), the E/M code would be based on the 25 minutes (99214 for an established patient or 99202 for a new patient visit).
With regard to your second question, according to the CPT guidelines, the counseling time and total-visit time apply only to physician/patient interactions. Time spent with the patient by an RN, LPN, or medical assistant does not count toward this physician/patient time; therefore, it cannot be used to increase the total time of the visit. Note, however, that some payers will allow “counseling time” to be billed by a nonphysician practitioner, if this person provided the entire service. (Note: In these cases, payers usually require that the non-physician practitioner be a nurse practitioner, certified nurse-midwife, physician’s assistant, or certified nurse specialist.)
This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.