Details Matter for Time-based E/M Services

Documentation must meet certain conditions for you to consider time as the key factor for the E/M level.

Most evaluation and management (E/M) services are coded based the level of history, exam, and medical-decision-making documented by the provider. But when the provider spends more time counseling and coordinating a patient’s care than anything else, using time as the controlling factor will capture the level of service more appropriately.

Know CPT® Requirements

To determine when you may use time as the key or controlling factor for determining the level of an E/M service, refer to specific conditions outlined in the CPT® Evaluation and Management (E/M) Service Guidelines:
Counseling or coordination of care must dominate (more than 50 percent) the patient encounter.
The E/M service must have a “reference time,” identifiable in the code descriptor by the statement, “Typically, X minutes are spent face-to-face with the patient and/or family.” The reference time provides an objective standard to determine whether more than 50 percent of the visit is spent in counseling and/or coordination of care.
In the context of office and other outpatient visits, “time” refers specifically to time spent face-to-face with the patient, as well as “time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members.” Time may include floor/unit time in the hospital or nursing facility.
The extent of the counseling and/or coordination of care must be documented in the medical record.
Although all of the above must be true to report E/M services based on time, the final point bears special emphasis. Providers justifiably feel bogged down by documentation or coding requirements that seemingly have little to do with patient care, but in this case the documentation requirements match clinical best practice and necessity.

Time Deserves No Less Attention than History, Exam, or MDM

When a provider documents an E/M service based on the history, exam, and MDM, sufficient detail must be provided to determine the “level” of each of these individual components. The provider does not document, for instance, “I performed a comprehensive history.” The provider must document detailed information relevant to the history of present illness (HPI) descriptors, such as location, quality, severity, etc., the number of body systems reviewed, and so on.
Based on these details, and using the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services or another audit tool, you can determine the extent of history (i.e., problem-focused, expanded problem-focused, detailed, or comprehensive). Similarly, the extent of the exam and MDM is not based on a single statement; it is calculated based on the number and type of details the provider documents for each component.
The same logic holds true when documenting time. It’s not enough to note how long the service lasted, or that counseling or coordination of care dominated. The documentation must explain the content of the visit to support time as the controlling factor, as well as to support overall medical necessity for the service.
The Medicare Claims Processing Manual, chapter 12, section 30.6.1.C states:
… when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. … the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim. [emphasis added].
Both the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services concur:
If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care. [emphasis added].
Best practice for providers documenting time-based E/M services is to note:

• The total time of the visit;
• The total time spent in counseling or coordination of care; and
• A synopsis of the discussion.

The note within the medical record can be a thorough account of the activity with the patient, the recommendations, and the patient’s concerns. The physician shouldn’t limit the documentation to only the time and counseling information, but should also include information gathered from the history and examination elements, as well as MDM concerning ordered and reviewed tests, co-morbid conditions, etc., to further substantiate the level of service and the time spent counseling.
Quantity of documentation, however, does not equal quality: Irrelevant or redundant details may detract from the quality of the medical record.
The medical record serves many functions — as a means to assign codes for payment, as a legal document, etc. — but, primarily, it’s is a “snapshot” of the patient’s condition at a given moment, and a tool to communicate with other providers. Never mind what a coder or auditor sees: Would another provider (or even the same provider, referencing the record weeks or months later) be able to determine what was discussed at the visit, based on the documentation provided? A medical record lacking pertinent details about the content of a counseling session, or what coordination of care at a particular visit entailed, fails at its primary, clinical purpose.
Warning! A snag that providers often get caught in is mentioning time in broad terms. Coders and auditors cannot use time to determine the level of service when providers indicate they had a “lengthy discussion” with the patient. Without the requirements included in the documentation, time cannot be the determining factor for the E/M service level.

An Example of Proper Documentation

I saw Mr. Patient today for his continuing complaint of knee pain. His MRI illustrates a meniscus tear that was helped with a cortisone injection some months back. However, he feels the knee is unstable and although usually active, it is limiting his ability to perform all of the things he would like to. We talked about surgery, additional cortisone shots, physical therapy, and doing nothing. He is concerned about surgery because of timing with his job. He was pleased with the last cortisone shot, but doesn’t want to rely on the uncertainty of needing it again and again. He has very little arthritis in the knee.
Upon examination, he is having tenderness at the area of the tear. No new complaints of any other new issues around skin, neurological or circulation. But he is concerned about the decline in his mobility. After answering some more of his more basic questions regarding healing time, anesthesia complications, and driving capabilities, he decided to move forward with the surgery. We scheduled this for next week. I was with him for 45 minutes, of which 35 minutes was spent in this thorough discussion.
The provider in the above example mentions history elements around the knee, associated pain, modifying factors, timing, and severity. He discusses a review of a few systems, as well. He also touches on an examination element where the knee was sensitive. The bulk of the visit and documentation was focused on the discussion. The physician was thorough in outlining what was discussed, the patient’s concerns, and the outcome. He also properly documented the time “details” (total visit time and time spent counseling/coordinating care) needed to report the service using time as the controlling factor.

Suzan Hauptman, MPM, CPC, CEMC, CEDC, is the senior principal for ACE Med group specializing in auditing, assessments, coding, compliance, expert opinion, writing, reporting, and education. She is experienced in leading teams of coders, auditors, and educators, as well as educating providers on medical record documentation, EHR, and HIPAA. She has served on the AAPC Chapter Association board of directors and the AAPC National Advisory Board, and sits on a number of other advisory boards throughout the industry. She is vice president of the Greater Pittsburgh, Pa., local chapter.

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