counseling/coordination

Comments

  • News to me! Hoping that wasn't one of my crew that is at that same meeting or she'll have some explaining to do lol.

    Donna


    Donna M. Beaulieu, CRC, C-CDIS, CPC-I, CPMA, CPC, CEMC, CIMC, CEDC, CFPC, CCP-P, CRP
    Certified Green Belt Lean Six Sigma
    Assistant Director, Patient Financial Services

    [Emory Healthcare]



    From: Roy Edroso [mailto:REdroso@decisionhealth.com]
    Sent: Monday, October 17, 2016 4:54 PM
    To: Multiple recipients of list PARTB-L
    Subject: [partb-l] counseling/coordination

    Hello -

    I'm at AHIMA (whee) and someone in a roundtable said something that seemed odd to me: That a lawyer consulting to her group said that if more than 50% of an encounter was devoted to counseling and coordination of care, the provider *had* to bill time-based.

    She said the lawyer referred to the use of "shall" in the Manual, though I can't find anything like that and she couldn't point it out.

    Does any of this ring a bell? It's totally news to me.

    Best,
    Roy

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  • Here is the claims processing manual...

    https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

    Around page 39...


    "C. Selection of Level of Evaluation and Management Service Based On Duration of Coordination of Care and/or Counseling

    Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. 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 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 in order 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 upon 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."

    I could see how one could devise this based on the wording.

    Most providers I know consider that an alternative approach. Meet the level of care based on documentation in the record and work done OR code based on time, if counseling/coordination of care are applicable and more than 50% of the encounter is face-to-face counseling.

    Karl Ellzey
  • As Karl posted, the Medicare's manual does not use the word "shall." While initially the manual language simply says that time "is" the controlling factor for counseling-dominated encounters, it then says that doctors "may" document time and bill based on it. Far from a 100% that billing based on time is absolutely mandatory just because the encounter is counseling-dominated.



    So now look at the language in Medicare's official 1995/1997 E/M Documentation Guidelines, where it says this:



    If the physician elects to report the level based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.



    So if the mere fact that an encounter was counseling-dominated in-and-of-itself absolutely obligates a provider to always base the level on time, there would be no choice involved, as the guidelines language indicates there indeed is.



    Also, while we’re at it, CMS does say in CERTAIN DOCUMENTS AND CONTEXTS (like program transmittals and change requests) that ‘“shall’ indicates a mandatory requirement (for the contractor), and ‘should’ denotes an optional requirement” (for the contractor), or something like that. Outside of those specific documents where this is indicated, Medicare can actually be quite sloppy as to the use of “should” and “shall,” and obviously does not in all cases intend these to always mean “mandatory” and “optional.” You can easily find some absolute requirements that are worded as only something you “should” do, and other optional requirements where Medicare said “shall.” (As a couple examples, look at the wording from the E/M Guidelines mentioned above. See where it says the provider “should” document their time in the record to bill based on time, and “should” document their counseling/coordination-of-care activities? Yeah, those are not optional requirements. Both are mandatory. Another example: in the TP Guidelines within the claims processing manual, the manual says a TP “should” reference a resident’s note in order to use info from that note, but again, that’s actually a mandatory requirement, not just a suggestion). You just can’t take these words as literally when presented outside the context of a specific document for which a clear reference within that specific document says that these two words absolutely means “mandatory” and “optional” within that one document.



    Now if you look at the equivalent language regarding time-based encounters in the CPT manual (the E/M Guidelines section), it does indeed say “time shall be considered the key or controlling factor to qualify for a particular level…” But CPT does NOT state that “shall” means “mandatory”/”absolutely always.” And If you look at other language used by CPT in regards to billing for counseling-dominated encounters, you’ll see language indicating there is choice involved. For example, here’s what CPT said in the December 2004 (p. 19) CPT Assistant which discussed billing for counseling-dominated encounters:



    From a CPT coding perspective, time may be considered the key or controlling factor when the physician provides counseling and/or coordination of care that dominates (more than 50%) the patient and/or family encounter.



    As Karl pointed out, folks for many years have realized that even though some language exists that superficially indicates that counseling-dominated encounters MUST be billed based on time, other evidence suggests the physician may indeed choose to bill based on this option, or decline it, and that understanding has been the one accepted within the industry (auditors and coders alike) for many years.


    Seth Canterbury, CPC, CPC-I
    Clinical Data Quality Education Department
    University of Florida Jacksonville Physicians, Inc.
    653 West Eighth Street
    Tower I, Suite 606
    Jacksonville, FL 32209





    -----Original Message-----
    From: Karl Ellzey [mailto:karl@ellzeycodingsolutions.com]
    Sent: Monday, October 17, 2016 7:12 PM
    To: Multiple recipients of list PARTB-L
    Subject: re:[partb-l] counseling/coordination



    Here is the claims processing manual...



    https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf



    Around page 39...





    "C. Selection of Level of Evaluation and Management Service Based On Duration of Coordination of Care and/or Counseling



    Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. 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 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 in order 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 upon 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."



    I could see how one could devise this based on the wording.



    Most providers I know consider that an alternative approach. Meet the level of care based on documentation in the record and work done OR code based on time, if counseling/coordination of care are applicable and more than 50% of the encounter is face-to-face counseling.



    Karl Ellzey
  • Well, I think some state whichever is more appropriate i.e. advantageous to the provider, I sort of have a problem with that though when there is a time statement present. It doesn't make sense, it's either one or the other. I have a group for which I code that does that, they say you have to level it either way if the HEM is higher than code to that and not on time; If that then is the case I would think that an amendment of a note would have to be done to cancel out the time statement-right.

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382

    From: Roy Edroso [mailto:REdroso@decisionhealth.com]
    Sent: Monday, October 17, 2016 13:54 PM
    To: Multiple recipients of list PARTB-L
    Subject: [partb-l] counseling/coordination

    Hello -

    I'm at AHIMA (whee) and someone in a roundtable said something that seemed odd to me: That a lawyer consulting to her group said that if more than 50% of an encounter was devoted to counseling and coordination of care, the provider *had* to bill time-based.

    She said the lawyer referred to the use of "shall" in the Manual, though I can't find anything like that and she couldn't point it out.

    Does any of this ring a bell? It's totally news to me.

    Best,
    Roy

    ______________________
    R o y E d r o s o
    Part B News
    http://pbn.decisionhealth.com/










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