When to Code Your E/M Service Based on Time
At KMC University, we get a lot of inquiries regarding the proper coding for Evaluation and Management (E/M) services. Often discovered in our advanced analysis services, we find many practices leave significant money on the table due to E/M coding errors. It is necessary to always code appropriately for any service that is performed not only because of potentially lost revenue, but also to reduce risk in the event of an audit. Therefore, it is so important for offices to stay up to date on coding edits and payer rules.
Let’s Start at the Beginning
The E/M services performed for new patient visits, initial visits starting an episode of care, and re-evaluations are usually based on three key elements: History, Exam and Medical Decision-Making. You notice once of these is not time. One of the most common mistakes made in E/M coding is that providers attempt to code their services based on the length of time spent.
We are commonly asked about billing for the Report of Findings (day two) visit with the patient to discuss overall findings and their treatment plan as it typically takes a good portion of time for the doctor and staff. This is a big misconception. The truth is, there are no codes to describe this standalone service as it is a continuation of the Medical Decision-Making portion of the initial E/M service. When you separate the new patient experience over two visits/days, it is simply delaying portions of the Medical Decision-Making element of the E/M service.
The Time Exception Clause
As for other E/M service scenarios outside of those mentioned above, there is a time exception clause. There may be some encounters where the three key components are not applicable. For example, in the case of a patient who presents to the office to discuss the results of blood work, an MRI, or other diagnostic study, there is no need to take a History or perform a physical Examination. The CPT manual states the following:
“When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services.”
This means that time alone may be used to override the selection of a level of care, regardless of the extent of the History, Exam or the Medical Decision-Making, if most of the encounter involves counseling or coordination of care. For E/M services, counseling may include a discussion of test results, diagnostic or treatment recommendations, prognosis, risks and benefits of management options, instructions, education, compliance or risk-factor reduction.
Documentation of Time
With all that said, how does one document the time spent? Use the bullet points below as a guide:
- State the length of time spent counseling/coordinating care (e.g., 15 mins, 25 mins)
- Total visit time (start and stop time to be recorded).
- If total visit time is the same as the time spent in counseling and/or coordinating care for the patient, it should be stated as such. (e.g., 25-minute visit with 25 minutes spent counseling and coordinating care).
- List a summary of issues and items discussed
- Who was present? It is important to note who was present, (e.g., husband and wife), because it helps to substantiate the amount of time spent, as now it will reflect questions are being addressed for two people instead of just the patient.
Documentation of Counseling
Although there are many items bulleted, document only those that are applicable.
- Discussion of significant medical problems
- Treatment options
- Potential risks and benefits
- Long-term impact and arrangements
- Involvement of family members/caregivers
- Amount of time and discussion to include other providers (only if the patient is present)
- Coordination of care with other providers
Use the Appropriate E/M Code
Assuming the patient is an established patient, the code falls within the code range of 99212-99215 (remember not to consider 99211 if the doctor is part of the delivery of service). Also, it is important to note that CMS states you cannot round up to a next level code based on time. Below are the times associated with the individual codes when there is a time exception.
- 99212 – 10 mins
- 99213 – 15 mins
- 99214 – 25 mins
- 99215 – 40 mins
KMC University has in-depth training on the proper usage of the E/M coding within our Library compendium. We also offer analysis services that can evaluate your proper code usage which can lead to missed money and reimbursement challenges.
Call (855) 832-6562 now or click to schedule a 15-minute Solution Consultation at your convenience.