Selection of Level of E/M Service Based on Duration of Coordination of Care and/or Counseling

Time is the key factor in selecting the level of service when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/ patient encounter or floor time (in the case of inpatient services). There are three key components when selecting the appropriate level of E/M service provided: history, examination, and medical decision making. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.

Example:
A cancer patient has had all preliminary studies completed and a medical decision to implement chemotherapy. At an office visit the physician discusses the treatment options and subsequent lifestyle effects of treatment the patient may encounter or is experiencing. The physician need not complete a history and physical examination in order to select the level of service. The time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.

Office/Other Outpatient Setting:
Counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician 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 physician service provided.

Patient is not present in the office:
Counseling/coordination of care with the patient’s family alone (i.e. patient is at home) is not a billable service.

Patient is present in the office:
If the family members/provider needs to perform counseling/coordination of care away from the patient they may leave the room and go to the hallway/private room. Time with the family may be included in the selection of the CPT code.

Inpatient Setting:
Counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient. Time spent counseling the patient or coordinating the patient’s care after the patient has left the office or the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported.

The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.

Documentation must include the following:

  • Duration of counseling/coordination of care (the duration may be documented as total time or a statement that identifies that more than half the time was counseling/coordination of care e.g. greater than 50 percent was spent on counseling/coordination of care)
  • Duration of the visit (may be total time or time in/out)
  • Sufficient documentation to support counseling/coordination of care

Resources:

  • Medicare Claims Processing Manual (100-04), Chapter 12, Section 30.6.1 C.

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