Pediatric Coding Alert

There are some misconceptions floating around that can wreak auditing havoc, however, and Rae Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, senior vice president of products at AAPC, cleared many of them up in “Risk Associated with Coding Time,” her recent presentation at HEALTHCON Regional 2022.

Review the Activities That Can Count Toward Time

Per the 2021 CPT^® guidelines, the full list of activities that you can use to count time includes:

• “Preparing to see the patient (eg, review of tests)
• “Obtaining and/or reviewing separately obtained history
• “Performing a medically appropriate examination and/or evaluation
• “Counseling and educating the patient/family/caregiver
• “Ordering medications, tests, or procedures
• “Referring and communicating with other health care professionals (not separately reported)
• “Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
• “Care coordination (not separately reported).”

“One of the most common misconceptions on reporting an E/M based on time is that a provider is required to document the time spent on each specific task associated with the visit,” says Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics LLP in Northampton, Massachusetts. The provider needs to instead document he total time personally spent on the above-listed activities on the date of the encounter.

Here are three issues that auditors see as time-related red flags.

Red Flag 1: Rounding Up the Total Time

Rounding up will surely raise red flags to an auditor. It might not seem like a big deal to round up a few minutes on each encounter, turning 16 minutes into 20, or 25 into 30. It is easy for your pediatrician to not pay close attention to their watch. “That’s a little difficult and I understand there’s some frustration with that, but you don’t want the time to look the same for every single patient,” said Jimenez. Think about it this way: when physicians round up on every patient, it has a dramatic effect by the end of the day. Adding an extra five minutes to each patient could end up looking like each physician spent hours longer at the clinic than they really did. Inflating time, whether intentional or not, is not best practice.

Note: Time spent by ancillary staff does not count in the physician’s total E/M time. If a patient comes in for a follow-up and sees a nurse practitioner (NP), that NP is going to start to evaluate any new patient complaints. Then the patient would likely consult with your pediatrician about the problem and a new treatment plan. “The time they spent in the room together is going to count only once. So, if the nurse practitioner spent 10 minutes with the patient, then invites the physician in and they spend 15 more minutes together, it’s going to be a total of 25,” said Jimenez.

Red Flag 2: Not Documenting Services Performed Out of the Office

Some red flags might count in favor of the physician. “The AMA defines time for E/M coding as the total time (based on minutes) the provider spends on the date of service during which a provider personally rendered services related to the patient’s care, even if the times are not consecutive,” explains Walaszek. So, what’s sometimes happening is physicians are forgetting to document all of their time.

As long as those services are accounted for in the record and are performed on the same day (for example, reviewing labs after the encounter), you can justify that time if an auditor questions it. Be careful, though, not to double-count that time if the pediatrician and NP spend time discussing a problem outside of the room after the encounter.

Red Flag 3: Misrepresenting Other Billable Services

Some services are billable but don’t get counted for time when they should. This would be the case when your pediatrician documents how many minutes they spent with the patient but they don’t include the time spent preparing to see them. This is common for physicians who are still accustomed to documenting in-office visits based on face-to-face time.

On the other side, sometimes services get counted twice. For example, for many minor surgeries, the E/M is built into the CPT^® code for the procedure, so carving out time spent there would result in the physician getting paid twice. Pay close attention to which procedure codes include the E/M, and you’ll be sure to not make that mistake. Also, pay close attention to the documentation. “If the physician is performing other billable services, add a note that says, ‘total time is 20 minutes excluding other billable services,’ so that in an audit there is no question,” said Jimenez.

Takeaway: Don’t Be Afraid of Time-Based Leveling

Using time to level an encounter is not only perfectly legitimate, it’s often in the physician’s best interest to code this way. The documentation has to be precise, though, in order to justify the time spent. When auditors perform time-based audits, “they will look at your schedule for the day and see how much time was worked, then total up all your visits. If you coded based on time and those hours add up to 20, but the actual hours worked was only 10, that doesn’t add up,” said Jimenez.

Fixing these issues before they become bigger issues might be a matter of more precise time reporting. Rounding up, forgetting to document same-day out-of-office time, and misrepresenting other billable services will all lead to inconsistencies during an audit. The best thing to do is study the patterns of the practice and see if there are any anomalies. As always, be sure to keep an open line of communication between your coding department and your physicians.