Go Beyond the Basics of Time-Based E/M Coding

When time captures reimbursement, every minute counts.

By G. John Verhovshek, MA, CPC
As CPT® evaluation and management (E/M) service guidelines explain, “When counseling and/or coordination of care dominates … the physician/patient and/or family encounter … time may be considered the key or controlling factor to qualify for a particular level of E/M services.” Specifically, in the office setting, time-based E/M coding requires that the physician spend half or more of the visit face-to-face with the patient and/or family providing counseling and/or coordination of care.
In a hospital or nursing facility, the counseling/coordination of care time needn’t be face-to-face, but may include floor/unit time within a 24-hour period. CPT® E/M guidelines allow unit/floor time to include “the time that the physician is present on the patient’s hospital unit and at the bedside rendering services for that patient. This includes the time in which the physician establishes and/or reviews the patient’s medical chart, examines the patient, writes notes and communicates with other professionals and the patient’s family.”

Time Reference are Crucial

Only those E/M services with a time reference may be reported using time as the key component. The time reference is stated in the final sentence of the CPT® E/M code descriptor. For instance, consider the descriptor for new patient outpatient service 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. Note that it specifies, “Physicians typically spend 30 minutes face-to-face with the patient and/or family.” In contrast, according to CPT® guidelines, “Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity bases.” Likewise, observation codes 99234-99236 do not have a time reference. Because these services do not include time references, you should not report them with time as the controlling element.
With regard to time references, CPT® explains that “specific times expressed in the visit code descriptors are averages and, therefore, represent a range of times that may be higher or lower depending on actual clinical circumstances.” In other words, not every level III, new patient, outpatient service (99203, as described above) will last 30 minutes. Conservative coding suggests the stated time reference is the minimum necessary to report a service by time. For instance, to report 99203, the visit would be at least 30 minutes, with at least 16 (50 percent or more) spent on face-to-face counseling and coordination of care. To report a level IV, new patient, office visit (99204) by time, the visit would need to last at least as long as the stated time reference of 45 minutes, and so on, as shown in Table A.
Note that time spent taking the patient’s history or performing an examination does not count as counseling time.

Count the Minutes, Note the Substance

Documentation is crucial when reporting time-based E/M services. As CPT® explains, “The extent of counseling and/or coordination of care must be documented in the medical record.” Actual start and stop times for the service, if ideal, are not necessary. What is required, however, is the physician’s note for how long the session lasted (e.g., “28 minutes”), as well as what portion of that time was devoted to counseling and/or coordination of care.
Just as importantly, documentation should describe the substance of the counseling and/or coordination of care, advises Marcia Brauchler, MPH, CPC, CPHQ, with Physicians’ Ally, Inc. in Littleton, Colo. For example, CPT® instructions allow counseling to include discussion of one or more of the following:

• Diagnostic results
• Prognosis
• Risks and benefits of treatment options
• Impressions
• Instructions for management
• Importance of compliance with chosen treatment options
• Risk factor reductions
• Patient and family education

A common example is a patient with a new diagnosis of diabetes. The physician may spend extensive time with the patient discussing lifestyle modifications, including proper diet and exercise, as well as the nature of the disease, the importance of control, and so forth. The substance of the discussion should be included in the physician note to support an E/M service coded by time.

Use It, Don’t Abuse It

Coding E/M services by time is simpler than reporting services according to history, exam, and medical decision making (MDM), but don’t be tempted to report all E/M services by time. Keep in mind: the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services’ (CMS) guidelines consider history, exam, and MDM to be the key components of E/M services, and allow coding by time only when 50 percent or more of the visit involves documented counseling and/or coordination of care. The physician should include the components of history, exam, and MDM—even if cursory—in the documentation of every visit. Good medical record keeping requires documenting relevant and pertinent information. Using time as the controlling factor to qualify for a given E/M level does not negate this requirement.

Time-based E/M and Prolonged Services

Prolonged services codes (+99354-+99357) may be combined with other E/M services to report extended, face-to-face patient/provider visits. To report prolonged services, the physician must document at least an additional 30 minutes of face-to-face beyond the time reference of the chosen E/M service level, as illustrated in Table A. Do not report prolonged service codes in addition to any E/M services (such as observation services) that do not include a time reference.
Heads up: Codes +99358 Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, communication with other professionals and/or the patient/family); first hour (List separately in addition to code(s) for other physician service(s) and/or inpatient or outpatient Evaluation and Management service) and +99359 Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, communication with other professionals and/or the patient/family); each additional 30 minutes (List separately in addition to code for prolonged physician service) report non face-to-face prolonged services, but these are not recognized by Medicare and many other payers.
Time counted toward prolonged services need not be continuous, but it must occur on the same service date. Do not consider time spent discussing the patient’s case with other physicians, time reviewing data or tests without the patient present, or other activities not involving direct patient contact toward prolonged services.
Documentation must explain why the physician provided prolonged services. For example, CMS Internet Only Manual instructions state, “to support billing for prolonged services, the medical record must document the duration and content of the E/M code billed.” A notation that the physician spent an extra 40 minutes with the patient, for instance, is not adequate. The medical record must support specifically medical necessity for the extra time spent.
Combining prolonged services with time-based E/M services raises interesting issues, Brauchler notes. “Looking at Pub. 100-04, Medicare Claims Processing Manual, chapter 12, section 30.6.15.1, you don’t have to max out the highest E/M level to add prolonged service time. This doesn’t necessarily make sense if you’re using time-based coding because, for instance, a 75 minute 99213 ought to be (by definition) a 99215, not a 99213 with 99354.”
Here’s the answer: Generally E/M levels are assigned according to history, examination, and MDM. If the physician spends 30 minutes or more beyond the time reference of the chosen E/M level on counseling and coordination of care, you’d apply prolonged services codes. If the physician spends fewer than 30 additional minutes beyond the reference time of the appropriate E/M level (as determined by history, exam, and MDM) with the patient—and counseling and coordination of care exceed 50 percent of the time allotted to the visit—you may choose to code a higher E/M level based on time.
For example, the physician sees an established patient with a newly-confirmed diagnosis of cancer. Based on the components of history, examination, and MDM, the visit warrants only a level III visit (99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.). The physician spends an additional 40 minutes (beyond the 15-minute time reference of 99213) answering questions and discussing treatment with the patient. In such a case, you could report the office visit (99213) and one hour of prolonged services (99354 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (eg, prolonged care and treatment of an acute asthmatic patient in an outpatient setting); first hour (List separately in addition to code for office or other outpatient Evaluation and Management service)).
If the same patient presents for the same visit but lasting 20 additional minutes beyond 99213’s 25-minute time reference, don’t report prolonged services (because the 30-minute threshold for 99354 was not met). But, as long as the physician spends more than half the visit on counseling and coordination of care, you may use time as the key component when assigning the E/M level (which, in the case of this 45-minute visit, would result in a level V service, 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family).

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