Step 1: Know the Requirements According to CPT guidelines , when counseling or coordination of care dominates the physician/patient encounter, that is, it comprises more than 50 percent of the visit, "time may be considered the key or controlling factor to qualify for a particular level of E/M services."
The January 1998 CPT Assistant explains further: "Counseling and coordination of care may include discussing one or more of the following areas with the patient: diagnostic results, impressions and/or recommended diagnostic studies, prognosis, risks and benefits of treatment options, instructions for treatment and/or follow-up, importance of compliance with chosen treatment options, risk factor reduction, and patient/family education."
Let's apply this principle to CPT's example of a standard interventional radiology E/M service: "Follow-up office visit for a 55-year-old male, two months after iliac angioplasty with new onset of contralateral extremity claudication." (Based on standard documentation for this type of encounter, CPT suggests that the visit might fall into the level-four, 99214, category.)
Suppose the patient is anxious and extremely concerned about the possibility of a blood clot. The interventionist spends 75 minutes discussing the patient's progress following the angioplasty, the patient's current symptoms, possible diagnostic tests required, potential treatment options, and preventive measures to alleviate discomfort. Because counseling and coordination of care dominated the encounter, you can use time as the controlling factor when assigning the E/M service level.
Step 2: Consult Standard E/M Times To determine the appropriate E/M level for the time spent with the patient, you should check the reference time included in the CPT descriptor for each code, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center based in Absecon, N.J. For instance, the descriptor for 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...) states, "Physicians typically spend 25 minutes face-to-face with the patient and/or family."
Remember that to qualify as a given E/M level based on time, the physician must spend at least half the total time (which should meet or exceed the reference time of the chosen code) on counseling or coordination of care. Therefore, if the interventional radiologist documents spending 55 of our [...]