Q: E/M for New Patient – For new patient physician visits, if the physician has not
performed the 3 key elements, can I bill the visit as a new patient or can I use the time
element?
A: Again, you want to go right to the manual.
In your E&M section of CPT, they’re got these guidelines here and they’re kind of
hidden, you got to dig for it.
But it’s under the section where they’re telling you to review the level of E&M service
descriptors and examples.
We just talked about the three key elements: history, exam, and medical decision making.
Then, there’s counseling, coordination of care, nature of presenting problem and time
– these are called the contributory elements.
The reason I have my: “Locate your HEM and Time” fill-in-the-blank thing tool, is the
Time part is sometimes Time is what you want to code by, even when you have these bullets
and that’s what the person is asking.
In the guidelines it says: “The first of these components (history, examination, and
medical decision making) should be considered the key components in selecting the level
of E/M services.
An exception to this rule is the case of visits that consist predominantly of counseling or
coordination of care” – that’s your key, that’s the permission slip.
Now it says go to page 10 and look at numbered paragraph 3.
That’s what we’re going to do right here.
What you’re seeing, guys, is the highlighting and underlining and the star.
I mark up my CPT book extensively.
What I’m doing is I’m just making things jump out at me; it’s not cheater notes or
anything like that.
They’re taken right from the guidelines normally a few pages ahead or right what’s
in front of me, I just make it jump out.
So here’s an example of that.
If you’re a Blitz customer, that’s my review video for those preparing for the CPC
exam, I have it so that you can see every single note that I’ve written in my CPT
manual.
My document camera basically films my CPT book so that you can pause it and copy the
notes.
Number 3: “When counseling and/or coordination of care dominates (more than 50% of) the encounter
with the patient and/or family (face-to-face time in the office or other outpatient setting,
floor/unit time in the hospital or nursing facility), then time shall be considered the
key or controlling factor…”
So, it’s one or the other, you’re going to code by the HEM or you’re going to code
by Time.
And it’s not your choice.
You only have the option to code by time if counseling or coordination of care dominates.
Let’s say the physician did a level four, if you were going to do it by the HEM, you
did all your figuring.
But then, he decided the patient is really sick, we really need to get them admitted
maybe to the hospital, maybe the nursing home.
Something where they’re coordinating care or they’re spending a lot of time counseling
the patient on something; so when they add it up, they realize out of maybe a 90-minute
session, they spent 45 minutes counseling or coordinating their care – well, then
time dominated and they can code by time.
So, that’s what these references are.
Here’s this example, 99343 is an example.
It talks about the three key elements.
And then this paragraph here: “Counseling and/or coordination of care with other providers
or agencies are provided consistent with the nature of the problem(s) and the patient’s
and/or family’s needs.
Usually, the presenting problem(s) are moderate to high severity.”
– That’s one of the other components – “Physicians typically spend 45 minutes face-to-face with
the patient.”
So, here’s the time reference.
We can use that if more than half of the time we spent counseling or coordinating care for
the patient.
Maybe they only spent 20 minutes doing this level 3 visit, but if they spent 25 minutes
counseling them, well then that dominates; so they can go ahead and bill a higher level
code based on the time.
So they can code a 99343 if the total time was 45 minutes.
And you code by total time, you don’t code by the counseling time.
You just need to know the counseling time was more than half of the total time, but
you use the time reference for the total time that the E&M visit took.
So, the key, the physician has to document time.
In physician education, what you want to train them to do is, say, “I spent 25 minutes
out of 45-minute session counseling the patient on…” or “Coordinating care to get them
in ABC Nursing Home.”
And that is how you document it to code based on time.
So, that’s your E/M fun for the night.