Does the phone in your office ring off the hook when medical news hits Yahoo’s landing page? The bubble above your patient’s head reads, “Do I need a statin?” “To mammogram or not to mammogram?” “Is hormone replacement therapy really that bad for you? Because I can tell you, my nights are really bad.” And, when these patients meet with the doctor they say, “I don’t need to be examined. I just want to talk with her.” As if talking might not constitute a visit.
But it does.
A physician or Non-Physician Practitioner (NPP) may bill for discussion visits, even if no physical exam is done. Even if it is a new patient. How? By using time to select the level of Evaluation and Management (E/M) service. Here’s what the CPT book says, “When counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for a particular level of E/M services. … The extent of counseling and/or coordination of care must be documented in the medical record.”
That is: if more than half of the visit is spent in discussion of the patient’s condition or diagnosis, possible diagnostic tests needed or their results, the risks and benefits of treatment options, education and the importance of compliance, time and not the key components of history, exam and medical decision making determines the code. This does not mean all visits can be determined by time, and physicians and NPPs should refrain from documenting time in all visits. Document time in these cases:
- Patient returns for follow up visit with surgeon after biopsy and imaging. At the visit, the patient and doctor discuss treatment options.
- Primary care physician “reads the riot act” to a patient with chronic conditions who is not making life style changes. (I read it in a note. Do you think it helped?)
- Worried patient comes to the office having heard the news that the recommendations for using statins have changed. The patient wonders if this means she should or should not take the medicine.
What should the physician document?
- Describe the discussion. It doesn’t need to be a he said/she said note. But, describe what advice was given and what the patient’s thoughts are. Usually, two to four sentences in the plan section does this. Try not to have it be entirely templated statements filled in with quick text.
- Document total time, and that more than 50% was spent in discussion/counseling. In the office, count only the provider’s face-to-face time, not office time or staff member time.
- Look in the CPT book for the typical times for each visit.
And, switching bands, remember what Mick said, “Time is on your side.” But I say, “Time is on your side, but only if you document it.”