Let’s go to the source! Should this visit be downcoded?

This article describes the use of time using the 1995/1997 guidelines. Be sure to read about the 2021 guidelines for codes 99202–99215.

A physician asked me this question:

“As an interventionalist, a good part of my visit is spent not only explaining patients’ conditions to them but discussing various diagnostic/therapeutic procedures, the risks and benefits and whether to consider surgery. Recently I had a 99215 challenged. I documented >40min more than 50% in face-to-face counseling and detailed all of the matters discussed. I was told it should be down-coded to 99214 despite the time spent as the level of medical severity was not sufficient for a 99215.”

• This article uses the 1995 and 1997 documentation guidelines, in effect in 2020.  Starting in 2021, the rules for codes 99202–99215 will change.

Source citations for coding and compliance

What would you do? Code the visit at a lower level based on medical severity or code the service based on time?   At times like this, I like to go to the source and in this case the source is CPT^®, the Documentation Guidelines and the Medicare Claims Processing Manual. Of course, we would suggest that the physician not document time saying “>40 minutes” but would indicate the time spent. “45 minutes.” This is true using the existing guidelines and the 2021 guidelines.

CPT^® coding rules using 1995/1997 guidelines

Do you read the preface or introduction when you start a book? I’ll admit, I often skip to chapter 1.  However, in the case of the CPT^® book, I’ve made an exception and I pay careful attention to the introductory material (numbered with Roman numerals) and to the section before the E/M codes, the E/M service guidelines.

First, CPT^® defines counseling:

“Counseling is a discussion with a patient and/or family concerning one or more of the following areas:

Diagnostic results, impressions, and/or recommended diagnostic studies

• Prognosis
• Risks and benefits of management (treatment) options
• Instructions for management (treatment) and/or follow-up
• Importance of compliance with chosen management (treatment) options
• Risk factor reduction
• Patient and family education”

Next, CPT^® tells us what we can include in the
counseling time—not pre and post visit work,
only face-to-face time:

Face-to-face time (office and other outpatient visits and office consultations): For coding purposes, face-to- face time for these services is defined as only that time spent face-to-face with the patient and/or family. This includes the time spent performing such tasks as obtaining a history, examination, and counseling the patient.

Finally, CPT^® tells us what to do:

“When counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for a particular level of E/M service.”

This seems crystal clear to me. The physician notes that she was discussing risks and benefits, and CPT^® calls that counseling.  Time is noted, and that more than 50% was spent in counseling.  And notice what CPT^® says in the last sentence, above.  “…then time shall be considered the key or controlling factor.”  Not may be, if the patient is sick enough or the presenting problem is severe enough.  Shall be.

The Documentation Guidelines, a joint work product of the AMA and CMS

The Documentation Guidelines are not silent about this issue.  Here’s what the Guidelines themselves say.

“D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CARE

In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.

DG: If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.”

Medicare Claims Processing Manual, Chapter 12

Finally, the Claims Processing Manual addresses this issue.

“C. Selection of Level of Evaluation and Management Service Based On Duration of Coordination of Care and/or Counseling

Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.”

So, do I agree that the visit should be down-coded to a 99214 for medical severity?  No.  Follow CPT^® and CMS rules and report a 99215.

Remember: the rules for using time for codes 99202–99215 are changing, effective Jan. 1, 2o21.