Time may be considered a key factor in selecting the level of service when at least half of the encounter consists of counseling or coordination of care.
This point is well taken by those with business savvy and also is captured by certain language in current procedural terminology (CPT). Certain codes recognize the increased expense associated with the time spent on certain services as well as on variations of services. Failure to use these coding options can cost your practice a significant amount of money over the course of the average year.
Coding for evaluation and management services such as office visits (both new and established patients) and consultations may be affected by the time spent on the service. Although lengthy visits are not common in daily ophthalmology practice, such visits do arise periodically. Some patients are not physically able to cooperate well with the exam. This adds time to the encounter. Other patients have increased encounter times because of the complexity and/or severity of their conditions.
Counseling may involve areas such as prognosis, risks and benefits of treatment, and instructions. Coordination of care includes communication with other providers. Counseling, rather than coordination of care, will be the more frequent factor in ophthalmic practice.
Time is measured in different ways depending on the site of service. For office visits and consultations, time is defined as "face-to-face" time. For visits in the hospital, time is defined as time spent on the patient's medical unit.
Documentation of time must be present in the encounters for which time is used as the determinant of the level of service. Total time, time spent in counseling or coordination of care, and the nature of the counseling should be recorded.
The time criteria applicable for office visit codes: 30 minutes for CPT 99203, 45 minutes for 99204, 60 minutes for 99205, 15 minutes for 99213, 25 minutes for 99214, and 40 minutes for 99215.
Considering these criteria and the typical reimbursement for the evaluation and management codes compared with that for comparable eye codes results in some basic rules. (Remember that at least half of the encounter must involve counseling or coordination of care in these examples.)
Specifically, do not use code 92004 (comprehensive eye exam) on a new-patient exam exceeding 45 minutes, 92012 (intermediate eye exam) on an established-patient exam exceeding 25 minutes, or 92014 (comprehensive eye exam) on an established-patient exam exceeding 40 minutes. The better choices, using time as the key factor, would be 99204, 99214, and 99215, respectively.
The time criterion applicable to code 99244 (office consultation) is 60 minutes. Therefore, do not use any lesser code (such as 99243) for a consultation exceeding 60 minutes.
Another option available to capture the additional effort involved in especially lengthy visits is the prolonged services code set in CPT. The codes most likely to be used would be CPT +99354, prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour; and +99358, prolonged evaluation and management service before and/or after direct (face-to-face) patient care (e.g., review of extensive records and tests, communication with other professionals and/or the patient/family); first hour.
These codes are add-on codes (as denoted by the plus sign) and are reported in conjunction with other evaluation and management services. Note that +99358 describes services performed outside the presence of the patient.
Medicare (but not all private payers) has determined that the non-face-to-face prolonged service codes (such as +99358) are not separately payable. This determination was made because the code valuation for evaluation and management services already accounts for the non-face-to-face work.