By Carolyn Buppert
Carolyn Buppert, JD, NP is a health care attorney. Her legal clients include medical practices, institutions, non-profit organizations and individual clinicians throughout the United States. She is the author of eight books, and her column offers tips and advice on financial issues. Visit her website to learn more about her: www.buppert.com.
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Documenting a Level 5 Office Visit
Billing for Counseling
December 2009Nurse practitioners take pride in their ability to teach and counsel patients about their illnesses. Examples of counseling by NPs include:
giving diagnostic results or impressions
discussing prognosis
explaining risks and benefits of treatment options;
giving instructions for treatment or follow-up
discussing the importance of compliance with chosen treatment options
explaining how to reduce risk factors
educating patients and families
Billing for Time Spent
When counseling accounts for more than half the time of a face-to-face patient visit, a nurse practitioner or physician may bill on the basis of time spent. Face-to-face time refers to the time with the physician or nurse practitioner. Although RNs may be capable of performing the counseling, only physicians, physician assistants, or advanced practice nurses will be reimbursed. The Medicare Claims Processing Manual states: “Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, time spent by the other staff is not considered in selecting an appropriate level of service.”
To bill counseling on the basis of time spent, select an evaluation and management code that corresponds to the total time of the face-to-face visit. Codes and corresponding times are found in Current Procedural Terminology. For example, in the description of a level 5 established patient office visit, Current Procedural Terminology states: “Physicians typically spend 40 minutes face-to-face with the patient and/or family.” So if a face-to-face office visit with an established patient is 40 minutes and at least 21 minutes of that time is spent on counseling, you may bill a level 5 visit. If the visit is more than 40 minutes, you may be able to attach a modifier for “prolonged services.” See the description in Current Procedural Terminology.
For billing purposes, it’s necessary to document the length of the encounter and the subject matter discussed. The duration of counseling may be estimated, but that estimate and the total duration of the visit must be recorded. If history taking, physical examination, and medical decision-making are performed, document that as well.
Note that we are not talking here about preventive counseling. That is billed under the codes for preventive medicine services. See Current Procedural Terminology for a description of those codes.
Here is an example from the Medicare Claims Processing Manual of appropriate counseling:
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.
Billing in Various Settings
In a hospital or nursing facility, the code selection may be based on the total time of the face-to-face encounter at the bedside and the time spent on the patient’s hospital floor or unit. Time spent counseling or coordinating care may be counted and billed. In an office or other outpatient setting, counseling or coordination of care must be provided in the presence of the patient. Time spent counseling the patient or coordinating the patient’s care after the patient has left the office or the practitioner has left the patient’s floor or begun to care for another patient on the floor may not be counted.
Here is a statement from the Medicare Claims Processing Manual on counseling families in critical care:
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.
The patient is unable or incompetent to participate in giving a history and/or making treatment decisions, and
The discussion is necessary for determining treatment decisions.
For family discussions, the physician should document:
The patient is unable or incompetent to participate in giving history and/or making treatment decisions
The necessity to have the discussion (e.g., “no other source was available to obtain a history” or “because the patient was deteriorating so rapidly I needed to immediately discuss treatment options with the family”
Medically necessary treatment decisions for which the discussion was needed, and
A summary in the medical record that supports the medical necessity of the discussion.
All other family discussions, no matter how lengthy, may not be additionally counted towards critical care. Telephone calls to family members and/or surrogate decision-makers may be counted towards critical care time, but only if they meet the same criteria as described in the aforementioned paragraph.
Prolonged Counseling
If the counseling session is very lengthy, the clinician may append one or more of the prolonged visit codes. The rules for billing the prolonged services codes are in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.15. Here are examples of prolonged counseling situations, from the Medicare Claims Processing Manual:
A physician performed an office visit to an established patient that was predominantly counseling, spending 75 minutes (direct face-to-face) with the patient. The physician should report CPT code 99215 and one unit of code 99354.
A physician provided a subsequent office visit that was predominantly counseling, spending 60 minutes (face-to-face) with the patient. The physician cannot code 99214, which has a typical time of 25 minutes, and one unit of code 99354. The physician must bill the highest level code in the code family (99215, which has 40 minutes typical/average time units associated with it). The additional time spent beyond this code is 20 minutes and does not meet the threshold time for billing prolonged services.
Be aware that Medicare auditors require that clinicians follow all of the above rules. So if submitting a bill for a 99215 office visit, be sure to include in the medical record the time spent, the subject discussed, and the necessity for the counseling. Omission of any of these elements from the medical record may cause an auditor to deny payment for the service.
Sources
American Medical Association. Current Procedural Terminology. 2009
Center for Medicare and Medicaid Services. Documentation guidelines for the evaluation and management codes, 1997.http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp
Medicare Claims Processing Manual. http://www.cms.hhs.gov/Manuals/IOM/list.asp