Urology Coding Alert

Choose your E/M coding approach wisely.

Many physicians are most comfortable coding their E/M services based on the degree of history, exam, and complexity documented, but don’t forget – or let your provider forget – the alternate method for choosing a level of service: time. As the old saying goes, time is money – and sometimes coding based on time can bring higher reimbursement for counseling or coordination of care services.

Follow the Formula for Factoring Time

Numerous elements of a patient’s visit come into play when deciding whether time should be used as the primary component when coding the encounter.

Simplify it: In order to code a visit based on time rather than the key E/M components of history, exam, and medical decision making (MDM), your provider must spend more than 50 percent of the visit performing counseling/coordination of care services. If the counseling/coordination of care services exceed the 50 percent threshold, and the documentation illustrates the total time of the visit, the time spent counseling and/or coordination of care, and what was covered by the counseling/coordination of care, you may determine the E/M code based on CPT^®’s typical time estimations.

Plus: You will use the entire time spent with the patient to determine the appropriate E/M code.

“Total time is counted only as face-to-face time for patients in an outpatient setting,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, vice president at Stark Coding & Consulting LLC, in Shrewsbury, New Jersey. “However, floor time may be counted for the total time for patients in the inpatient setting. Counseling time is face to face time, while coordination of care time can be floor time for inpatient status patients,” explains Cobuzzi.

Note:  The total time must meet or exceed an E/M code’s typical time designation in order to be coded as such. For example, if a provider exceeds the 50 percent threshold for a new patient visit and the total time is 35 minutes, you may code as 99203 (Office or other outpatient visit for the evaluation and management of a new patient ...) since the typical time for a 99203 service is 30 minutes. You should always round down to the nearest time estimation in these situations.

This is where the CPT^® manual comes into play. Under most E/M codes, you will find that CPT^® provides a time estimation for a typical E/M service. These estimations vary depending on patient setting and code level. For example, for a new patient visit, code 99201 (Office or other outpatient visit for the evaluation and management of a new patient ...) typically requires 10 minutes for a physician to complete all components of a visit at that level. On the other hand, code 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...) typically requires 5 minutes to achieve the same level of service.

But – Don’t Always Let Time Outweigh Other Components

As you look at all aspects of the patient’s visit, don’t fall into the trap of automatically coding based on time when counseling/coordination of care dominates the visit.

Here’s why: Sometimes coding based on the history, exam, and MDM will warrant a higher code level than basing your code selection on time. This is particularly true for an established patient visit, where the level of only two of these three components determines the code.

Background:  CMS states that if counseling and/or coordination of care takes up more than 50 percent of the face-to-face physician/patient encounter - or floor time in the case of inpatient services - time can become the key factor in selecting the level of service. Generally, to bill an E/M code, your physician must complete at least two out of three criteria (history, exam and medical decision making) applicable to the level of service provided for an established or follow-up patient, or three of three criteria if the visit is the initial service. However, your physician may document total 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, and notations of both total time and time spent counseling are required to bill an E/M as a time-based code.

Consider this example: During a 15-minute visit with an established patient, your physician spends more than eight minutes discussing treatment outcomes and possible problems of prostatitis. The patient also has several other conditions including diabetes and hypertension. The urologist documents a detailed history, an expanded problem-focused exam, and MDM of moderate complexity.

In this case, coding based on time would warrant 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity...), which has a reference time of 15 minutes for this visit if the documentation is sufficient to support the medical necessity for spending the time.

However, the history and MDM alone justify a 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; a detailed examination; medical decision making of moderate complexity...), which pays about $36 more than 99213 when performed in the outpatient setting. Therefore, your billing should be based on components, a detailed history and a medical decision making of moderate complexity: 99214. For this clinical scenario by billing on time alone, using 99213, you would be shorting your practice revenue due to you.

Bottom line: Your provider needs to assess the different components of time when treating all patients. Once he or she has properly documented these time components, it’s your job as the coder to determine whether time may override your typical E/M components of history, examination, and medical decision making.