Count Only Included Services when Reporting Time

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  • February 1, 2016
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Count Only Included Services when Reporting Time

When calculating time spent performing a procedure or service, include only those items specifically detailed in the code descriptor. For example, when reporting critical care services (e.g., 99291-99292), you may include the time spent interpreting cardiac output measurements or chest X-rays, performing ventilatory management or vascular access, and other services enumerated within CPT® as inclusive of critical care. You may not count toward critical care the time spent performing other, separately reportable services (e.g., endotracheal intubation for airway support, 31500).
Carefully review CPT® guidelines and code descriptors to determine which activities you may count toward the time of a particular service. Each code category or descriptor may include different components within a time-based code. For instance, critical care includes floor/unit time, in addition to time spent at a patient’s bedside. By contrast, when calculating time for prolonged services 99354-99357, you may count only face-to-face time. Many time-based services include only that time spent face to face with the patient. Count time away from the patient only if the code descriptor or other CPT® guidelines specifically allow you to do so.
Bonus tip: As a best practice, when providing time-based services, you should document start and stop times, as well as the total time of service.

Evaluation and Management – CEMC

John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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