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). In general, the
physician must complete at least two out of three criteria applicable to the type/level of service provided to bill an E/M code. 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 is made 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 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 code selection is based on the total time of the face-to-face encounter or floor time, not just the counseling time. The medical record must be documented in sufficient detail to justify the selection of the specific code if time is the basis for selection of the code.In the office and 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 on the physician service provided.
In an inpatient setting, the 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.
