Published in the July 2006 issue of Today’s Hospitalist
Because this is my first article for Today’s Hospitalist, I thought I would address a commonly asked question: How do I bill when I spend most of a visit in a discussion with a patient or a patient’s family on issues such as prognosis, treatment options or test results?
In my years as a coder, I’ve found that many physicians either don’t bill for this service or bill for a low level of service. They assume that because an exam may have not been indicated, or because they performed only a very limited exam or didn’t take a history, they can’t provide the elements they need to bill for the service.
This is not true! If you spend more than 50 percent of the visit counseling the patient, you can bill based on time for the visit.
If someone other than a physician spent time talking to the patient, you can’t bill Medicare for patient counseling.
Here’s how it works. It’s true that payers don’t generally allow you to count time as a factor in choosing a level of service. When counseling dominates the time you’ve spent with the patient, however, you can do just that, and bill based on the duration of the visit.
Your code selection remains the same as if you were performing a traditional visit based on the history, exam and decision-making, e.g., a subsequent hospital visit (CPT codes 99231-99233). But there is a plus to time-based billing: You don’t have to meet the onerous evaluation & management (E/M) documentation requirements of his¬tory, exam and decision-making.
While you get to take a pass on the usual requirements for an E/M service, that doesn’t mean you’re completely off the hook in terms of documentation. To support these visits, you still need some documentation.
Here’s a review of the three elements that you must document for a time-based service.
Total duration of visit
The total time you spend with the patient determines the level of service. That’s important, because if you don’t document the time you’ve spent, you can’t support the level of service you choose.
When documenting time, include only the time you spend face-to-face with the patient. If a nurse or other hospital member counseled the patient, you can not include it; you can count only physician counseling time.
Total time spent counseling
Your documentation needs to demonstrate that more than 50 percent of the visit was spent on counseling. This can be done in various ways.
One way is to simply say, “Visit time 30 minutes, counseling time 20 minutes.” Some physicians alternately use a statement that says, “This was a 30-minute visit, with greater than 50 percent counseling.”
It is very important to note that Medicare only pays for face-to-face time with the patient, so you can not bill Medicare for time spent on conversations without the patient present. If you have a conversation with both the family and the patient, make sure you document the patient’s presence.
Medical necessity for counseling the patient
You can demonstrate that the time you spent on counseling was medically necessary by briefly summarizing what you discussed with the patient.
The following will suffice: “30-minute discussion with patient regarding abnormal lab results, diagnosis possibilities, treatment options, risks and benefits. The patient had many questions and concerns regarding these options and the long-term effects.”
Stating “lengthy conversation with patient,” on the other hand, will not work. If you’re ever audited about this service, you will not be able to support the medical necessity because your documentation contains no detail about the discussion.
You may have had a lengthy conversation about the weather that day, or you may have discussed other inconsequential information that was not medically indicated.
Calculating time
The chart on the next page gives an overview of the total time requirements for the three different categories of hospital codes that are typically used by hospitalists. You must meet or exceed the time requirements to qualify for each level.
As an example, let’s look at the code we would select for a patient who was seen in the hospital for a visit that lasted a total of 30 minutes, 20 minutes of which were spent counseling the patient.
First of all, you would determine the category of service that was provided, choosing from admit, consultation or subsequent hospital visit. You would next select the code based on the total time you spent in that category, which in this case is 30 minutes.
If this was a subsequent visit, you would select CPT code 99232. In this case, you could not bill 99233 because you would not have reached the 35 minute threshold.
A few other points to remember. Because this would be the only E/M service you would bill for that day of service, make sure that it encompasses all the evaluation services you’ve provided to the patient for that day.
In addition, your code selection is based on the total visit time, not just the time you spent counseling the patient.
For my next article, in the September issue, I’ll be discussing documentation for subsequent hospital visits. If there is a topic you would like covered, please let me know and I’ll try to address it in an upcoming issue.
Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at kristywelker@hotmail.com. We’ll try to answer your questions in a future issue of Today’s Hospitalist.
