Carolyn Buppert, NP, JD


June 06, 2008


As oncology nurse practitioners in a private practice, we have been asked to provide educational visits formerly done by the RNs. These visits are scheduled for 1 hour and do not include history or physical examination. Medical decision making includes prescribing medications needed prior to and following chemotherapy. Should a Level 4 visit be used for these sessions?

Response from the Expert



Response from Carolyn Buppert, NP, JD
Attorney, Law Office of Carolyn Buppert, PC, Bethesda, Maryland

You may qualify for a Level 5 visit. When more than half of the time of a face-to-face office visit is spent on counseling, a nurse practitioner or physician may bill on the basis of time spent.[1] Select an evaluation and management code that corresponds to the total time of the face-to-face visit. Codes and corresponding times are found in Current Procedural Terminology.[2] Current Procedural Terminology states, in the description of a Level 5, established patient office visit: "Physicians typically spend 40 minutes face-to-face with the patient and/or family." So, if a face-to-face office visit with an established patient is 40 minutes, and 21 minutes of that time is spent on counseling, bill a Level 5 visit. If the visit is more than 40 minutes, you may be able to attach a modifier for "Prolonged Services." See the descriptions for these modifiers in Current Procedural Terminology.

Examples of counseling are:

  1. Giving diagnostic results, impressions, and/or recommended diagnostic studies;

  2. Discussing prognosis;

  3. Discussing risk and benefits of treatment options;

  4. Giving instructions for treatment and/or follow-up;

  5. Discussing the importance of compliance with chosen treatment options;

  6. Discussing how to reduce risk factors; and

  7. Educating patients and families.

Document the length of time of the encounter and the subject matter discussed. If history-taking, physical examination, and medical decision-making are performed, document those as well. The diagnosis needs to justify the counseling, but this should not be a problem in an oncology practice.

Readers may ask: "Why are the nurse practitioners doing the counseling?" The answer is that nurse practitioners will be reimbursed and RNs will not. Nurse practitioners may provide "physician services." The Medicare Claims Processing Manual states, regarding counseling: "Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, time spent by the other staff is not considered in selecting an appropriate level of service. The code used depends upon the physician service provided."[3]


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