Ordinarily, a hospitalist's daily evaluation and management (E/M) level of service is determined by the extent of history obtained from a patient, the extent of the physical examination performed, and the complexity of medical decision-making. Yet in certain situations, counseling and coordination of care services can help determine the E/M code to assign, according to the American Medical Association's Current Procedural Terminology (CPT®).
When counseling and/or coordination of care comprise more than 50% of total time spent providing all hospital services (whether continuous or discontinuous) on a given date, then total unit/floor time is considered the key factor to qualify for a particular level of E/M service. The key components (history, physical exam and medical decision-making) must still be provided and documented for the day, however, or an E/M service cannot be billed. When counseling and/or coordination of care are conducted without a patient encounter, they are reported using case management—not E/M—codes.
CPT® defines counseling as discussion with a patient or related party concerning one or more of the following areas:
- Diagnostic results, impressions, and/or recommended diagnostic studies
- Risks and benefits of management (treatment) options
- Instructions for management (treatment) and/or follow-up
- Importance of compliance with chosen management (treatment) options
- Risk factor reduction
Counseling includes time spent with parties who have assumed responsibility for the care of the patient, such as family members, foster parents, persons acting in loco parentis and legal guardians.
Coordination of care is communication with other clinicians or agencies regarding the nature of the patient's condition and the needs of the patient and family.
The total time involved in the patient's care for the day and the time committed to counseling and coordination of care must be documented in the medical record. Include in patient care all time spent at the bedside and on the floor/unit continuously available to the patient, but not elsewhere. Don't include time spent performing any separately billable services. Counseling and coordination of care time may occur in any hospital location or by phone.
When counseling and coordination of care constitute more than 50% of the total time, the E/M level of service is based on the average time that CPT® codes assign to the E/M service (see box at left for average times). For example, a subsequent inpatient encounter requiring a total time of 40 minutes, including more than 20 minutes of counseling and coordination of care, would be assigned code 99233. History, physical and medical decision-making must be performed that day to bill for an E/M service, but counseling and coordination of care determine the level.
When counseling and/or coordination of care constitute more than 50% of the total time spent providing all hospital services for a patient, the total time will determine the level of service for that day. Counseling and coordination of care do not replace the three key components of an E/M service that must also be provided and documented. To determine the level of service, the total time is compared with the average time assigned by CPT® to the E/M codes.