Timely Tidbits: CPT® 2013 Clarifies Time-based Services
When time is a key factor, follow these five basic rules.
By G.J. Verhovshek, MA, CPC
For 2013, the American Medical Association (AMA) updated their CPT® codebook to better explain the rules for time-based codes. The revised instructions can be found in the Introduction section of the CPT® Professional Edition (page xii), under the subhead Time. The guidelines stipulate that—in the absence of specific instruction to the contrary (whether in a parenthetical reference, code-range-specific rules, or the code descriptor)—there are five basic rules when reporting time-based services.
1. Time Means Face-to-face Time with the Patient
Time spent away from the patient is not billable unless a specific code describes the non face-to-face, time-based services; or, if coding guidelines otherwise allow for time spent away from the patient. For example, CPT® provides time-based codes to report prolonged services without direct patient contact (99358-99359). Time billed for these services is not face-to-face with the patient, but occur before and/or after patient care.
Note that even “face-to-face” services may allow you to count some non face-to-face time, as long as it bears directly on patient care. For example, time-based critical care codes 99291–99292 include “time spent on the unit or at the nursing station on the floor reviewing test results or imaging studies, discussing the critically ill patient’s care with other medical staff or documenting critical care services in the medical record.”
To be sure you are reporting all appropriate time, read all code descriptors and coding guidelines for the code category you are reporting.
2. A Unit of Time is Attained when the Midpoint is Passed
For example, if a code describes the “first hour” of service, you don’t need to document a full 60 minutes to report the code. But at least 31 minutes of service (or “past the midpoint” of 60 minutes) must be provided and documented. If the unit of service is 30 minutes, at least 16 minutes must be documented to report the code. If the unit of service is 15 minutes (therapy codes are an example of these), eight or more minutes should be documented.
The CPT® codebook often provides charts with time ranges to help you report time-based services appropriately. For an example, see the “Total Duration of Critical Care Codes” chart within the Critical Care Services subsection of the Evaluation and Management chapter.
If the minimum time to report is not met, either the service is not billable, or you should instead bill an (other) appropriate evaluation and management (E/M) service code (e.g., office visit 99212–99215). For example, if fewer than 30 minutes of critical care (99291) are provided, CPT® instructs you to report “appropriate E/M codes.”
Some codes describe “24-hour services,” as does 95950 Monitoring for identification and lateralization of cerebral seizure focus, electroencephalographic (eg, 8 channel EEG) recording and interpretation, each 24 hours. For these codes, at least 12 hours of service must be documented to report the code. For services lasting fewer than 12 hours, you may need to append a modifier, such as modifier 52 Reduced services.
3. When There Are Two Time-based Choices, Pick the Closest
CPT® states this rule as, “When codes are ranked in sequential typical times and the actual time is between to typical times, the code with the typical time closest to the actual time is used.”
The rule applies when reporting E/M services using time (rather than the key components of history, exam, and medical decision-making) as the controlling factor to qualify for a given level of service—that is, when counseling and/or coordination of care comprises more than half the encounter. In such a case, use CPT® “reference times,” along with patient status and place of service, to determine an appropriate E/M service level.
For example, a level III established patient outpatient visit (99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity) has a reference time of 15 minutes, while a level IV service (99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity) has a reference time of 25 minutes. If counseling equaled 18 minutes, the closest reference time is that of 99213, at 15 minutes, so you would report 99213. If, instead, the service lasted 22 minutes, the closest reference time is the 25 minutes of 99214, and you would report that code.
4. Don’t Combine the Time of Unrelated Services
“When another service is performed concurrently with a time-based service, the time associated with the concurrent service should not be included in the time used for reporting the time-based service,” CPT® explains. Put more simply, don’t count the time of an unrelated service when reporting a time-based service.
For example, time spent providing separately reportable procedures or services should not be included toward critical care time (as reported using 99291, 99292). Only time spent performing services or procedures specifically within the CPT® definition of critical care may be counted toward critical care time.
Be aware that what counts as “time” varies by the kind of service provided. For instance, critical care services include floor/unit time in addition to time spent at a patient’s bedside, while other time-based services do not. The requirements for critical care are different than those of standby services, prolonged services, or any other time-based service. You’ll have to read section guidelines and code descriptors to know exactly what you can count as “time” for any given service.
5. For Continuous Services, the Date of Service Doesn’t Change
Suppose you begin a time-based service at 10:30 p.m., and that service lasts until 1:30 a.m. the next day. Per CPT®, “For continuous services that last beyond midnight, use the date in which the service began and report the total units of time provided continuously.” For instance, if intravenous hydration is given in the time described above, you would report 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour once and +96361 Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure) twice.
Best Practices Bonus Tip
Whenever possible, physicians providing time-based services should report not only the total time of service, but also start and stop times. The additional detail goes a long way to support and justify your coding choices.