Samuel A. Collins
Q: What code can I bill for a report of findings?
A: A report of findings is a component of an evaluation and management (E&M) service (codes 99201 through 99205 and 99211 through 99215) under counseling. Counseling is an integral part of the E&M service and is part of the criteria for choosing the appropriate E&M code. Counseling, as defined in CPT 2006, is a discussion with a patient and/or family concerning one or more of the following areas:
- diagnostic results, impressions, and/or recommended diagnostic studies;
- prognosis;
- 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; and
- patient and family education.
Therefore, a report of findings is included in the initial E&M service; it is not a separate service requiring its own code. This counseling component of the E&M service typically is done in one patient encounter. If the counseling (report of findings) is conducted on a separate or subsequent visit, it could be appropriate to bill an additional E&M service, but it must be justified as to the necessity of two E&M services being performed on consecutive visits. The use of E&M services on subsequent visits is a scenario that should not be routine, but unusual, as most cases would not have the complexity to require it.
If a provider prefers or has a routine to do the counseling (report of findings) on a separate, subsequent visit, it likely would not be appropriate to bill any additional code for the counseling, as that component already was included in the prior service. There is nothing wrong in performing the service in this way, but this "style" does not increase the amount of the billing or the codes utilized, as the same level of services were performed (but were simply divided). If a provider feels he or she deserves to bill an additional E&M code for the service, they must have adequate documentation and justification of such, as there is a greater chance of audit on this type of claim.
