Published in the May 2004 issue of Today’s Hospitalist
In a hospitalist practice, it is typical for physicians to devote a huge amount of time to the counseling and/or coordination of care. Try to get adequately paid for that time, however, and you’re likely to find that the elements within the history, exam and medical decision-making (MDM) value do not allow you to bill for anything but the lowest level of service.
The good news is that when you find yourself in this type of situation, you can make sure you’re paid what you deserve by selecting the level of service based on time. The catch? The service must meet the counseling and coordination-of-care guidelines outlined by the AMA.
Put simply, those guidelines say that when counseling and/or coordination of care account for more than half of your encounter with a patient and/or family members, you can consider time the key factor in billing for a particular level of E/M service. (The guidelines refer to face-to-face time for office and outpatient visits, and floor/unit time in the hospital or nursing facility for inpatient care.)
Here are some tips to know when an individual patient encounter qualifies for a time-based level of service.
In the 2004 CPT, AMA guidelines clearly state that you don’t have to count only the time you’ve spent with patients. You can include the time you spend with individuals who have assumed responsibility for the patient or decision-making.
Those individuals do not have to be family members. You can include the time you’ve spent working with the patient’s foster parents, persons acting in locum parentis, legal guardians, etc.
Once you decide to bill for a time-based E/M service, you need to document the exact extent of the counseling and/or coordination of care services you’ve provided.
Guidelines from the Centers for Medicare and Medicaid Services, for example, say that when physicians choose to report a level of service based on counseling and/or coordination of care, they must document the length of the encounter at the bedside or on the patient’s hospital floor or unit. Time spent after the physician has left the patient’s floor or begun care for another patient on the floor should not be considered when selecting the level of service to be reported. The record must also describe the counseling and/or activities to coordinate care.
Defining counseling and coordination
Exactly what counts as a counseling service? CPT 2004 defines counseling as a discussion between a physician and the patient and/or family concerning one or more of the following areas:
“¢ diagnostic results, impression, and/or recommended diagnostic studies;
“¢ 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; and
“¢ patient and family education.
When it comes to coordination of care, CPT 2004 counts any time spent on the patient’s floor coordinating care with other providers or agencies. Keep in mind that this time must be directed at caring for only one patient.
While just about all E/M encounters include some level of counseling or coordination of care, the determining factor in whether you can bill for your time spent on these activities focuses on exactly how much time you spend on those activities. A coder or auditor will ask three basic questions to determine if the documentation supports time based billing:
1. Is total time documented?
2. Does the documentation describe the content of counseling/coordination of care?
3. Does the documentation show that more than half of your time was spent on counseling/coordination of care?
If the answer is “yes” to all three questions, you’re safe selecting a time-based level of service. Keep in mind that there should also be some basic elements met for the E/M service, and that you need to provide evidence of a patient encounter on that day.
While there are no clear guidelines as to exactly what your documentation must say, the three elements listed above must be easily inferred by reading your note. A note that says something like, “Total time: 60 minutes; 45 on counseling/coordination of care,” will not qualify a level of service to be based on time. Your notes must detail the counseling and coordination of care in order to support the level of service.
Cindy Catterson is president of Pro Fee Billing Specialists Inc., a Napa, Calif., company that works with physicians to improve their billing and collection systems. She can be reached through e-mail.