Problem Visits With Counseling

Question: I know that I’m allowed to bill for annual health maintenance visits as well as problem-oriented services on the same day. The thing that has come up is that sometimes the problem portion of the visit is counseling, and my office manager says I can’t bill for both services when the problem part involves counseling. Is this true?

Answer: Great question. The factual answer is that it is not true - you can bill for both when you perform both services. But what I suspect your office manager is alluding to is a potential documentation problem - and perhaps even a reimbursement problem with this scenario.

Normally when you bill the preventive code for the annual and an office visit code to cover the problems handled, the problem-oriented code is supported by the HPI and assessment and plan portions of the chart. Often the HPI takes the form of the status of various chronic ailments, but it can be the more acute descriptors normally associated with the HPI.

In your situation above - whatever the problems are that require counseling could easily meet these parameters, and as long as there is an HPI, maybe a small subjective ROS, and the requisite assessment and plan - you likely have documented the problem visit above and beyond the health maintenance one.

The potential problem arises if you try to bill the problem code based on time spent counseling. Often, when counseling is the predominant character of the visit - you can code for it by time - and the supporting documentation takes the form of “spent more than half of an X-minute visit counseling on Y.” And this is sufficient.

But realize that the times associated with the problem codes are total encounter time. The fact that you spent more than half of that time counseling simply qualifies you to use time to code. And therein is the potential problem at the heart of your question. The “total” encounter time in this case would appear to include the preventive service. To bill the problem portion based on time spent counseling, as opposed to the actual management reflected in the HPI/decision-making portions of the chart, you’d need to segregate the problem visit from the preventive visit in terms of time.

If this is the route you choose, you might try something like this: “Following the preventive portion of today’s visit, 30 minutes was devoted to addressing problem X. Of this 30 minutes, more than half the time was spent counseling the patient on Y.”

This should have the effect of separating the two different aspects of the encounter, and allow for a fairly concise description of the problem-oriented portion and its required supporting documentation.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or physicianspractice@cmpmedica.com.

This question originally appeared in the April 2010 issue of Physicians Practice.