Billing for the Inquisitive Patient

June 11th, 2012

All providers have at least one:  the inquisitive patient. 

Within minutes of entering the room, you have performed a sufficient history and physical and made your medical decision.  You are ready with a likely diagnosis and course of treatment.

Your patient, however, has spent much time self-diagnosing with online symptom checkers.  He came prepared with a folder full of his own research. 

Thus the majority of the visit is not involved with diagnosis and treating the patient.  Instead it is involved in explaining to the patient why it is unlikely he has blisters from  Paraneoplastic Pemphigus and more likely he has them from ill-fitting shoes.

The AMA’s CPT discusses billing based on time when counseling and/or coordination of care predominate an encounter.  CMS, does not always follow the AMA guidelines, but in this case, it does.

On page 3 of CMS’s 1995 Documentation Guidelines, CMS tells us:

An exception to this rule (of determining service level based on 3 key components)  is the case of visits which consist predominantly of counseling or coordination of care; for these services time is the key or controlling factor to qualify for a particular level of E/M service.

Likewise on page 4 of  CMS’s 1997 Documentation Guidelines, there is guidance on what to do in this situation:

In the case of visits which consist predominantly of counseling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service.

Thus CMS HAS provided you a way to bill for your time when you have an inquisitive patient. 

In order to bill for time, ensure the following are noted in your records:

1. The time spent face-to-face with the patient.  Ideally you will record start and stop time.

2. In the office, document that more than half of the face-to-face time was spent with the patient/and or family is counseling/coordination of care. For instance, "Saw the patient for 10:00 to 10:25 a.m. face-to-face; 20 minutes of that visit was spent in counseling.”  The rule is slightly different for an inpatient setting.  You may include time in the unit or floor when directly involved with the care of the patient.

3. A description or summary of the counseling/coordination of care provided.

Selecting the Proper Code

The CPT description of most evaluation and management codes include descriptions of the level of history, physical and medical decision making.  The codes will also include the amount of time a provider “typically” spends with the patient.  This is the time used to select the code.

The code selection is based on the total time of the encounter, not just the time involved in counseling/coordination of care. But counseling/coordination of care must exceed 50% of the encounter.   The medical record must contain the details listed above to justify the selection of the specific code if time is the basis for selection of the code.

Note that not ALL evaluation and management codes contain times.  For example, billing based on time in the emergency department is not an option since time is not included as a component of those codes.

Office or Other Outpatient Setting

In an office setting, the patient must be present when counseling and/or coordination of care services are rendered.. Face-to-face time refers to the time with the provider only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the provider service provided.  This is NOT an appropriate use of “incident to” for

Inpatient Setting

Counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit and be for the specific patient. Time spent counseling the patient or coordinating the patient’s care after after the provider has left the patient’s unit or begun to care for another patient in the unit should not be included in total time supporting the level of service.

Medical/Legal Consideration

Many providers practice “most likely scenarios” when treating patients with strict instructions to call back if there isn’t improvement or if certain new symptoms manifest.  When dealing with a patient with a handful of web articles and billing for counseling/coordination of care; be sure to take the time to document your differential diagnoses.  In the extremely rare case where the patient’s research is right, the standard is not whether you were right or wrong; but whether or not you were “negligent” with you diagnosis.

Tags: Counseling/Coordination of Care, Billing by Time, Documentation, Evaluation and Management


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