When NPs and PAs bill patient encounters on time, they must document sufficient details within the patient’s medical record that justify the selection of the code.

Are you losing a significant amount of revenue due to undercoding of patient encounters? It has been estimated that 20 to 30 percent of all office and hospital patient encounters are undercoded, resulting in a major loss of revenue.

Why do nurse practitioners (NPs) and physician assistants (PAs) undercode services? Studies point to a lack of training in coding guidelines and criteria, improper documentation of patient visit times and fear of incurring an audit. Indeed, non-physician practitioners may be shortchanging themselves and their practice.

Clinicians should always document the time they spend counseling patients. This counseling may involve answering questions and instructing them on medications. If the time you spend on counseling or coordination of care is greater than 50 percent of the entire patient encounter, you can select appropriate codes based on time. Ensuring quality patient care is obviously a priority so the amount of time one spends with a patient is a significant factor.

Accordingly, there are steps that can help clinicians provide optimal care while maximizing reimbursement.

When NPs and PAs bill encounters on time, they must document sufficient details within the patient’s medical record that justify the selection of the code. Non-physician practitioners should only count face-to-face time spent as counseling time. This is also separate from time spent on the history of present illness (HPI) or examination.¹

Also keep in mind that the usual documentation rules still apply when it comes to obtaining a patient history, performing an examination and medical decision making,and billing for an E/M visit. Clinicians cannot combine these times.

The average time of completion for a 99213 visit is 15 minutes. It is 25 minutes for a 99214 visit and 40 minutes for a 99215 visit, according to the American Medical Association CPT Manual.² In order to bill appropriately for counseling time above and beyond the usual E/M time, a NP or PA must document the total time spent in the encounter, the length of the counseling session during the encounter and the topic of the discussion. Practitioners should also make sure there is a distinct line or new paragraph visible seperating the counseling from the usual visit time allotted for the code they apply.

Billing For Prolonged Services: What You Should Know
When time is the main factor in billing for extra time on a patient encounter, both physicians and non-physician providers should look closely at the use of billing for prolonged services. The extra time spent should be significant and plainly stated in medical records.

Prolonged services codes for billable services surpassing the customary time are underutilized. In regard to the CPT codes for these types of services, they are as follows:
• + 99354: Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting). One should list the first hour separately in addition to the code for an office or outpatient visit.
• + 99355: Each additional 30 minutes. Be sure to list this separately in addition to coding for prolonged physician service. You should bill with the CPT code 99354 when you have spent an extra 30 to 74 minutes of face-to-face time with a patient. Clinicians should use the code 99355 for each 15- to 30-minute interval beyond the extra 74 minutes on the first code (99354). Keep in mind that you cannot bill with CPT codes 99354 and 99355 on an encounter if a prolonged visit is less than 30 minutes in duration.

It is also important to note that clinicians cannot bill with the prolonged services CPT codes 99354 and 99355 alone. These are add-on codes and clinicians must report them with another E/M code. Also, one can only report the CPT code 99355 after the main CPT code and after 99354.

Some physicians and non-physician practitioners may not document their time clearly enough to justify the use of the CPT codes 99354 or 99355. In order to receive the benefits of additional reimbursement for these services, clinicians should find ways to keep better track of circumstances in which they are spending a large amount of time with any patient.

Are You Documenting All Patient Complaints?
When a patient comes in with a number of complaints, a practitioner may only document some of the complaints. Be very careful about this as disregarding some of the complaints may result in severe undercoding of the claim.

For example, a 68-year old female patient with rheumatoid arthritis (RA) comes in for an E/M visit and is seen by a NP or PA. After the visit has been completed, she complains of severe pain in the elbow, shoulder and knee after a fall as well as long-term morning stiffness.

It has been estimated that 20 to 30 percent of all office and hospital patient encounters are undercoded, resulting in a major loss of revenue.

She reports taking a generic pain medication but wants to know if there are any other over-the-counter (OTC) medications she can take to alleviate the pain. The patient is also looking for any simple exercise routines that will not be overbearing.

Documenting only one of her complaints may produce documentation for a CPT code 99212 for the established patient. However, if the clinician lists and gives attention to every complaint, the documentation should support a 99213 or 99214 encounter.

The dollar amount may vary depending on each individual encounter. This difference may not seem substantial but when you multiply this over time and multiple patients one sees per day, it can add up to a significant increase in revenue.

High quality and complete medical documentation will include:
• the reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;
• assessment, clinical impression or diagnosis;
• the plan for care (which NPs and PAs can prepare if they bill the patient encounter independently);
• an NP and/or PA signature, and date and time of documentation;
• clear information and rationale for ordering diagnostic, and other ancillary services;
• past and present diagnoses relevant to the current visit;
• appropriate health risk factors; and
• the patient’s progress, response and change to treatment, and revision of diagnosis.

Clinicians must follow documentation guidelines in order to justify the level of the CPT codes they bill for the E/M service and the ICD-9 code(s).

In Conclusion
Good documentation is an important defense against compliance problems, which can take on even larger significance when it comes to avoiding unnecessary audits. Be wary of undercoding and take a good look at how you can prevent it. Physician practices may be significantly affected when the Centers for Medicare and Medicaid (CMS) and private carriers begin to further scrutinize claims.

Non-physician practitioners should become more involved in training on current ICD-9 and CPT coding guidelines, compliance and billing. There are many training options available for practitioners. These options include computer-based training, consultants, coding conferences and audio conferences.

Given the potential benefits that clinicians and practices can realize through accurate and complete coding, health care providers can no longer afford to overlook the importance of proper documentation. Indeed, having this knowledge may actually improve the bottom line for many practices.

Editor’s note: For a related article, see “What You Should Know About The National Provider Identification” in the May/June 2006 issue of Arthritis Practitioner.