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, thephysician 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.
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