Student Examinations; New vs. Established Patient Visits

Student Examinations

Q: If a patient is scheduled for a consultation with his provider, but is instead examined and seen by a student, and the provider consultation is rescheduled, is the subsequent visit with the provider a consult since a student is not reportable or billable?

A: You are correct. The visit with the physician can still be considered a consult. The first visit is not considered an encounter since the student isn't a licensed medical professional. In Medicare's view, no encounter is considered to have taken place for the first visit since there was no encounter with a provider.

Units vs. Separate Line Items

Q: When billing code 31500 more than once a day, should it be billed as three units or should it be billed indicating two or more separate lines of the same code (this code is 51 exempt)?

A: I'd bill it twice or more as separate line items with a -59 on the subsequent lines just to indicate "separate time/service." That is within the AMA definition of -59 and it will probably sit better with the payer. You could try it with units, but the payer would surely ask for supporting documentation.

Time-Based Coding Changes

Note: The reader posing the question below refers to a previous coding column that appeared in the March 2012 issue of Physicians Practice. The column referenced new explanatory text in the CPT 2011 Professional Edition, Page XII, which covers time-based codes. The text in the CPT 2011 reads: "When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the typical time closest to the actual time is used."

Q: I had a follow-up question regarding the time-based coding questions/answers you outlined in the March issue. The question is regarding the time-based coding changes that appear in CPT 2011/2012. If I see a patient for a follow-up visit for 60 minutes, with more than 50 percent of that time spent on counseling/coordination of care, I generally code a 99215. However, due to the changes you noted, am I now able to code a 99215 and a prolonged service code of 99354 for this visit if the total time I spend is 60 minutes?

I believe to code the 99354 I would have to spend at least an additional 30 minutes and up to an additional 60 minutes. So, I'm not sure if a total of 60 minutes qualifies as closer to the 70 minutes (for a 99215 and 99354), or if it needs to be closer to the upper limit of the prolonged service code of 99354 (100 minutes) to qualify.

Basically, I'm wondering what the minimum amount of time spent (with 50 percent spent on coordination of care/counseling) is to code a 99215 and 99354 for a follow-up visit? Is a minimum of 70 minutes total still required?

A: Your question is logical given the thrust of the March article, that the "typical times" aren't cast in stone - and that the new language of "closest to the actual time" does change things a bit.

However, when you begin talking about appending a code to the original and this new code represents additional time above and beyond the first code (the prolonged services code), the rules for prolonged visits state that these can only be coded once you have gone 30 minutes or more over the "typical time."

Granted, that definition precedes the newer time comments, but I still think it prudent to be conservative when asking for additional time. So to your example, a 60-minute visit with over half the time spent counseling is indeed a 99215. To qualify for the 99215 and 99354, you would need the 40-minute "typical" time associated with the 99215 plus 30 minutes of prolonged services, for a minimum threshold of 70 minutes. It's nice to see you thinking this carefully about it, but I'd stick with the "typical" time rule in this scenario. I hope that helps.

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 editor@physicianspractice.com.

This article originally appeared in the July/August 2012 issue of Physicians Practice.