A higher level of E/M may be reported if an internist spends the majority of an office visit counseling. If counseling exceeds 50 percent of an E/M encounter, time (not history, exam and MDM) dominates the chosen E/M code, and documentation of the exact time spent will substantiate the choice. Internists must document the counseling portion as well as the E/M portion of the visit so the service will not be downcoded in the event of an audit.
According to Scott Manaker, MD, an internist at University of Pennsylvania Hospital in Philadelphia, if a physician spends 25 minutes with a patient (established), of which only five minutes was used to document a low-level history (no physical exam was necessary) and the remaining 20 minutes was counseling, the doctor can legitimately bill 99214 (office or other outpatient visit for the evaluation and management of an established patient ... physicians typically spend 25 minutes face-to-face with the patient and/or family).
Face-to-face is defined as the one-on-one time the physician spends with the patient alone or the patient and family together, including obtaining a history, performing an examination and counseling. However, during this visit, time can also be reported for reviewing records and tests, arranging for further services, and communicating, either in writing or by telephone, with other professionals and the patient (as long as the patient is present).
Another important item to note is that Medicare requires the patient's presence during counseling with the family. And, Medicare wants the medical record to indicate what was discussed during the encounter. The discussion with the patient and/or the patient and his or her family should cover one or more of the following:
Risks and benefits of management treatment options
Instructions for management (treatments) and/or follow-up
Importance of compliance with chosen management options
Patient and family education.
Counseling During Regular Office Visit
Michael Haynes, MD, an internist and compliance director for University Medical Associates in Augusta, Ga., says that counseling often precedes other office visit services. For example, particularly in Haynes' sub-specialty of pulmonology, patients frequently come in to discuss complex test results, such as a biopsy that reveals cancer. Treatment options and the relative risks associated with them are discussed. In this case, the patient's options could be surgery, radiation or chemotherapy. The physician must determine what path the patient wishes to follow.
For example, an internist follows up with an established patient, an 80-year-old woman who had recently been seen for a lump she discovered in her breast. Her concerned family accompanies her to this follow-up visit to learn [...]