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The Doorknob Syndrome

Patient flow is running smoothly in your practice today. Suddenly, your efficiency comes to a screeching halt. And it only took five words from one patient: “oh, by the way, doctor…”

If this is a common occurrence in your practice, you have a case of the “doorknob syndrome.” Follow these recommendations to avoid letting last-minute requests disrupt patient flow.

Set an agenda. During the initial part of the visit, establish an agenda with the patient for the visit. Say, “Mr. Jones, I’m going to summarize what you’ve told me…  I’ll be addressing those concerns today. Is there anything else you’d like to discuss with me today?” Of course, this won’t guarantee that you’ll avoid every last-minute request, but it will prevent some of them.

Defer politely. Instead of responding to last-minute requests with a statement like: “I have a lot of patients to see…” or “I don’t have time for that…” confirm the importance of the patient’s request, and defer it until later. Declare that the question is so important, that you want to have enough time to discuss it. For example, state: “Mr. Jones, the issue that you are raising is so important that I’d like to allow enough time to thoroughly discuss it with you.” Ask the patient to schedule a follow-up appointment.

Handle the request. If the request isn’t urgent and you feel you have time to handle it, by all means, assist the patient. Avoid getting too caught up, however, and allow yourself to fall significantly behind schedule. An alternative is to give the patient the option to wait in the exam room and return after you see the other patients who are waiting across the hall for you.

Code appropriately – and get paid. Whether you perform the service because you have plenty of time – or the patient’s question needs to be addressed from a clinical perspective, be sure to document the care you provide regarding the extra question. It’s critical to include these so-called “doorknob” services in your coding.

According to the 2011 CPT® Manual, “When counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for a particular level of [evaluation and management] E/M services. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (e.g., foster parents, person acting in loco parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record.”

Thus, if counseling and/or coordinating care consumes more than half of the encounter, you can code the service based on time. Indeed, in this situation, time may be considered the critical factor to qualify for the level of the E/M code. To code based on time, you should record the duration of the entire encounter, as well as the time dedicated to counseling and/or coordinating care. To choose the code, refer to the time that the CPT Manual references for each E/M code. For example, 99214 is 25 minutes, so if you spend 14 minutes counseling and/or coordinating care, you can use the 99214 even if you haven’t met all of the history, exam or medical decision-making elements required to bill it. Of course, just because the rules focus on time, don’t randomly bring patients in just to counsel them – an auditor will still look for a medically necessary visit.

Many physicians forget about – or have never been made aware of — this coding rule. Because coders won’t pick up on it when performing chart abstractions if you fail to document the particulars of the encounter, this time is often not reimbursed.

If you fail to meet the guidelines of the time-based coding described herein, but you do perform a separately identifiable service, bill for the services you render. Add a -25 modifier to the office visit to indicate that the services you performed – a preventive visit and a problem-focused visit, for example — are distinct. Although not all payers will reimburse you for both visits, reimbursement responses from payers have become more positive for this scenario lately. See, for example, the results of the efforts of the American Medical Association, which address the payment of separately identifiable services in the settlement with Blue Cross Blue Shield.  Link to: www.ama-assn.org/resources/doc/psa/bcbsflyer.pdf

As with all coding issues, be sure to research the particulars with your coding guidebooks and seek advice from your internal coding experts or a coding consultant.

The doorknob syndrome may put a wrinkle in your efficiency, but at the very least, you deserve to get paid for it when it happens.

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Woodcock & Associates: Changing the Way You Work