EM Coding Alert

Use this Definitive Guide for Time-Based Coding.

Time-based E/M coding has always been the subject of a lot of misconceptions.

So, we reached out to our experts, and looked at some real-life examples, to produce this guide and clear up your clock-watching confusion.

Get the Background Info

As a refresher, you can bill your E/M visit based on time if “50 percent or more of the total time the physician/clinician spent providing services to the patient was in counseling or in efforts spent coordinating  care”, says Jennifer Lame, MPH, RHIT, a medical coding instructor with Southwest Wisconsin Technical College.

“The total time spent counseling the patient, coordinating care, as well as the time spent completing the key components (history, exam, medical decision making) are used as the total time for the visit,” Lame said. “The documen tation must support the extent of time spent counseling/coordinating care,” she said.

Documentation Is in the Details

The following must be included in the medical record when coding based on time, says Pearl Evelyn Parker Hartfield, CPC, CPC-I, a coding instructor with Antonelli College and a coder with A&L Medical Coding Consulting in Hattiesburg, Mississippi:

• Total time of the visit, not just time spent counseling
• The time spent counseling/coordinating care, demonstrating that more than 50 percent of the total visit time was dedicated to counseling and coordination of benefits and services
• A brief summary of counseling and coordination of care including decisions made, risks to the patient associated with treatment versus non-treatment, etc.

Know What Not to Do

Suppose your physician didn’t document any exam elements for a new patient, so you want to report a CPT^® code based on time. The electronic medical record (EMR) shows that he spent 20 minutes with the patient, and the notes reflect that they discussed the diagnosis and possible management options.

In this case, the physician will probably be unable to report any code at all, since the lack of a physical exam excludes the provider from reporting a new patient E/M code (99201-99205). Also, the fact that the note doesn’t say how much time was spent counseling/coordi­nating care excludes him from billing based on time.

In addition, the notation of total time spent should be in the documentation itself, not taken from a time stamp on the EHR. It’s possible that the physician began reviewing or dictating the patient’s record before even walking into the exam room with her, so the total time spent should be clearly marked and not based on the EHR’s time stamp.