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Current Procedural Terminology Coding

Evaluation and Management Services Coding Topics

Counseling/Coordination of Care

How should I bill if I spend 20 minutes of a 30-minute office visit counseling a patient and/or coordinating that patient's care?

Current Procedural Terminology (CPT) descriptors for levels of evaluation and management (E/M) services recognize seven components, six of which are used to define levels of E/M services. These components are:

  • history
  • examination
  • medical decision-making
  • counseling
  • coordination of care
  • nature of presenting problem
  • time

History, examination and medical decision-making are the key components in selecting a level of E/M service. Counseling, coordination of care and nature of presenting problem are contributory factors. These contributory factors are important but not required to be provided at every patient encounter. Time is included as an explicit factor to help physicians select the most appropriate level of E/M service. A "typical time" is assigned to most E/M codes.

You can use time as the key factor in selecting a particular level of E/M service when counseling and/or coordination of care accounts for more than half of the face-to-face time you spend with a patient.

You can code based on total time using the regular office visit codes (CPT 99201-99215) when counseling and/or coordination of care dominates the encounter.

Using the scenario presented in the question, you could code according to total face-to-face time-regardless of the level of history, exam and decision-making that you perform-because counseling and/or coordination of care accounted for more than half of the visit. Assuming that it was an established patient office visit, you would qualify to bill CPT code 99214 because the 30-minute encounter exceeded the "typical time" of 25 minutes for that code and fell short of the 40 minute typical time for CPT code 99215.

Be sure that the patient visit meets the CPT definition of counseling. CPT defines counseling as 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

Finally, it is important that you document the time you spend on counseling and/or coordination of care in the patient's medical record.

If I see a patient purely for counseling purposes, how should I bill?

If the patient is not ill and does not have any symptoms, some payers will reimburse you if you use the preventive medicine service codes for individual and group counseling (CPT 99401-99412). CPT provides the following definition of counseling:

"Preventive medicine counseling and risk factor reduction interventions provided as a separate encounter will vary with age and should address such issues as family problems, diet and exercise, substance abuse, sexual practices, injury prevention, dental health and diagnostic and laboratory test results available at the time of the encounter. These codes are not to be used to report counseling and risk factor reduction interventions provided to patients with symptoms or established illness."

Medicare does not provide reimbursement for preventive medicine services, however. In this case, your best option is to bill the patient directly.

Prolonged Services

CPT defines intra-service for hospital and other inpatient visits as unit/floor time. Accordingly, should I use unit/floor time when determining if I can bill Medicare for prolonged physician services with direct (face-to-face) patient contact in the inpatient setting-CPT code 99356 and 99357?

No. Although you typically consider unit/floor time when selecting the level of service to bill for inpatient care, the criteria for meeting the time requirements for billing the prolonged service codes are different. In order to bill Medicare for CPT code 99356 and 99357, the time you spend with your patient must actually be face-to-face. Codes 99356 and 99357 are used to report total duration of face-to-face time spent by a physician on a given date providing prolonged service. The time spent by the physician on that date does not need to be continuous. Code 99356 is used to report the first hour of prolonged service, and code 99357 is used to report each additional 30 minutes.

The method of accounting for time to determine if you should bill the inpatient prolonged service codes with direct patient contact is inconsistent with the other E/M inpatient CPT code descriptors, which use unit/floor time. (There are prolonged service codes for physician services without direct (face-to-face) contact, which are "bundled" by Medicare and are not separately payable.) Considering the circumstances that are necessary for billing these codes and that the criteria for meeting the time requirements are more stringent, CMS has indicated that these codes should be used infrequently.

Hospital and Nursing Facility Services

Will Medicare pay for both a hospital discharge management and a nursing facility admission service when a beneficiary is discharged from the hospital and admitted to a nursing facility on the same day?

Yes. Medicare will pay for a hospital discharge day management service, CPT codes 99238-99239, or a observation care discharge day management service, CPT code 99217, in addition to a comprehensive nursing facility assessment service, CPT codes 99304-99306 provided by the same physician on the same day.

CMS's payment policy is supported by the "Initial Nursing Facility Care" guidelines included in CPT, which state:

Hospital discharge or observation discharge services performed on the same date of nursing facility admission or readmission may be reported separately.

Medicare pays for both to allow physicians to be reimbursed for the total time they spend discharging a patient from a hospital or observation unit-performing activities such as a final exam of the patient, discussion of the hospital stay, and preparation of discharge records-in addition to the comprehensive nursing facility assessment.

Medicare will not pay for E/M services relating to a nursing facility admission that are provided to a patient in another setting on the same day as a comprehensive nursing facility assessment service, however.

CMS's payment determination is also consistent with CPT guidelines:

When the patient is admitted in the nursing facility in the course of an encounter in another site of service(e.g., hospital emergency department, physician's office) all E/M services provided by that physician in conjunction with that admission are considered part of the initial nursing facility care when performed on the same date as the admission or readmission. If during the course of an office visit you decide to admit the patient to a nursing facility and perform the comprehensive nursing facility assessment service on the same day, you should consider the services related to admission that were provided in your office when selecting a level of service for the initial assessment.

Again, according to CPT:

The nursing facility care level of service reported by the admitting physician should include the services related to the admission he or she provided in other sites of service as well as in the nursing facility setting.

Consultation Services

(Note: CMS does not reimburse for Consultation Codes 99241 - 99255. For Medicare patients select the appropriate new or established patient visit code).

I often see patients at the request of another physician. Should I use the consultation codes when billing for the services I provide to these patients?

First consider what constitutes a consultation. A consultation usually occurs when a physician requests the opinion or advice of another physician on the evaluation and/or management of a specific problem.

During a consultative visit, a physician:

  • offers an opinion or advice to the requesting physician
  • makes a decision for treatment option(s)
  • performs and/or orders distinctive diagnostic and/or therapeutic procedures

To bill for a consultation, you must:

  • document your advice or opinion
  • document any services you performed or ordered
  • communicate this information back to the requesting physician

You must send a written report to the requesting physician detailing your findings. The physician who requests the opinion or advice must first document in the patient's chart the reason for requesting the consultation. If your encounter with a patient at the request of another physician meets these criteria, bill for a consultation.

In your documentation, identify the physician who asks for your opinion or advice as the "requesting" physician. Don't allude to the requesting physician as the "referring" physician; the term indicates a physician who has transferred a patient to another physician's care.

If I furnish a consultation and then I assume all or part of the patient's care, can I still bill the initial visit using the consultation codes?

(Note: CMS does not reimburse for Consultation Codes 99241 - 99255. For Medicare patients select the appropriate new or established patient visit code).

Yes. According to the general guidelines of the consultation section of the evaluation and management (E/M) service codes found in "Current Procedural Terminology (CPT) 1999," a physician consultant may initiate diagnostic and/or therapeutic services." Even though the physician initiates treatment during the initial service done at the request of another physician, the initial visit is still considered a consultation. Do not use the consultation codes, however, when reporting visits that occur after the completion of the initial consultation when you have assumed all or a portion of the patient's care. Keep in mind that you cannot bill a consultation when another physician transfers the care of the patient to you.

Miscellaneous Topics

Cardiovascular Stress Testing

How do I report it when I supervise a cardiovascular stress test in the hospital setting, and provide the interpretation and report?

The cardiovascular stress test CPT codes are designed to allow coding flexibility and to promote billing accuracy. CPT code 93015: "cardiovascular stress test using maximal or submaximal treadmill or bicycle, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report" is the base code that identifies a comprehensive cardiovascular stress test service performed on equipment owned by the physician. CPT codes 93016-93018 each indicate an individual component of this comprehensive service. You should choose the CPT code(s) that accurately reflects the service you provide.

Medicare prefers that you bill CPT code 93016, "physician supervision only" AND CPT code 93018, "interpretation and report only" when you supervise a cardiovascular stress test that is furnished in a hospital and you perform the interpretation and issue a report.

For non-Medicare third party payers, CPT recommends that physician supervision of a cardiovascular stress test, with interpretation and report-using institution-owned equipment-should be billed by appending modifier -26, indicating provision of the "professional" component of the service, to CPT code 93015. You should check with your non-Medicare payers to find out their preference for reporting the professional component of a cardiovascular stress test performed on hospital owned equipment.

For all payers, you should bill CPT code 93015 when you own the treadmill and perform the cardiovascular stress test-supervision, interpretation, and report-in your office or other setting.

Last updated: 11/24/2015