Question 2021 E/M Guideline Changes - Who can document time?

Anduiza05

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Ok, so the new E/M guidelines for 2021 have changed the time frames for the following codes.
Code Time
99202 15-29
99203 30-44
99204 45-59
99205 60-74
99211 N/A
99212 10-19
99213 20-29
99214 30-39
99215 40-54

According to the new guidelines, time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service. (50% rule is out)
The doctor still needs to document the activities associated with this encounter. Here is what they consider examples of time activities:
  • Physician/other qualified health care professional time includes the following activities when performed:
  • preparing to see the patient (eg, review of tests)
  • obtaining and/or reviewing the 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 (when not separately reported)
  • documenting clinical information in the electronic or other health records
  • independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
  • care coordination (not separately reported)
I have a question in regard to who can document the time. My doctor is stating we will never meet the new time requirements if they are the only ones documenting for this section of the medical record. Aside from obtaining a history section, I don't see where an MA or other non-clinical professional can document in the medical record to support the time code billed. Also, is an MA considered a qualified health care professional? I think there is no wiggle room for documentation based on the new rules but I would love to know what your doctors are saying about the new time requirements and again who do you think is a qualified healthcare professional.
 

csperoni

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I would think anyone could document the time (like a scribe), as long as that time was spent by the physician or qualified healthcare professional. Qualified healthcare professional is typically anyone who may independently bill for services (MD, DO, PA, NP, CNS). Here is an AAPC article about the exact AMA definition of qualified healthcare professional https://www.aapc.com/blog/28964-define-a-qualified-healthcare-professional/
MA, RN, LPN is NOT a qualified healthcare professional.

Remember that time is an option, not a requirement. You may use only MDM to determine the service level.
I expect to rarely use time, as it will most often not be documented well.
Here's what I expect to happen in reality for a straightforward follow up visit:
MD spends 3 minutes reviewing records/history prior to visit
MD spends 5 minutes on exam, then 5 minutes discussing the plan; follow up 3 months.
MD spends 6 minutes ordering labs, PETCT, and documenting the note
Total MD time: 19 minutes = 99212 on time alone

Here's what I expect the note to say regarding time:
nothing

Is he going to walk around with a stopwatch and track every minute he spent on each specific patient? Nope. Can I expect my staff to know when he is in his office for 20 minutes which patients he is reviewing and how much time spent on each? Nope.
I can expect the MDM to be properly documented that I am able to code this for 99212-99214 depending on the problems, changes, etc.

In the situation that there is a particularly involved patient, then time may be a good option.
Example situation: cancer follow up visit and patient is being discharged from practice
MD spends 3 minutes reviewing records/hx
MD spends 5 minutes on exam, then 18 minutes discussing with patient and spouse that she is now considered cured and no longer needs oncology services. Being discharged from specialty care. Recommends routine follow up with PCP and ob/gyn, etc.
MD spends 6 minutes documenting note
Total MD time: 32 minutes = 99214 on time alone

Assume MDM documented is level 2 (stable chronic illness, not ordering additional testing, low mortality/risk). I can HOPE my clinician would document time for this patient, since it was significantly more than usual for straightforward decision making.

For me, in daily E/M coding, I expect to use MDM only on >95% of visits, as I do now (for hx, exam, MDM). Occasionally there will be an unusual situation where the physician spends significant extra time. I have educated the clinicians to be sure to document times in those situations.

Maybe you work for a clinician that spends 20 minutes reviewing 10 years of records prior to each appointment. Or is technology challenged and it takes 5 minutes to order a lab test and 15 minutes to type a note. Or maybe you're pain management and the clinician spends significant time with patients to ensure medication compliance. If that's the case, then your clinician needs to track time and document it. But most clinicians with competent staff or scribes should be able to get a 99214 accomplished with less than 30 minutes of actual MD time.

I'll say it's nice to have the option, but I personally don't expect to use it any more often than I currently use time.
 

Anduiza05

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I would think anyone could document the time (like a scribe), as long as that time was spent by the physician or qualified healthcare professional. Qualified healthcare professional is typically anyone who may independently bill for services (MD, DO, PA, NP, CNS). Here is an AAPC article about the exact AMA definition of qualified healthcare professional https://www.aapc.com/blog/28964-define-a-qualified-healthcare-professional/
MA, RN, LPN is NOT a qualified healthcare professional.

Remember that time is an option, not a requirement. You may use only MDM to determine the service level.
I expect to rarely use time, as it will most often not be documented well.
Here's what I expect to happen in reality for a straightforward follow up visit:
MD spends 3 minutes reviewing records/history prior to visit
MD spends 5 minutes on exam, then 5 minutes discussing the plan; follow up 3 months.
MD spends 6 minutes ordering labs, PETCT, and documenting the note
Total MD time: 19 minutes = 99212 on time alone

Here's what I expect the note to say regarding time:
nothing

Is he going to walk around with a stopwatch and track every minute he spent on each specific patient? Nope. Can I expect my staff to know when he is in his office for 20 minutes which patients he is reviewing and how much time spent on each? Nope.
I can expect the MDM to be properly documented that I am able to code this for 99212-99214 depending on the problems, changes, etc.

In the situation that there is a particularly involved patient, then time may be a good option.
Example situation: cancer follow up visit and patient is being discharged from practice
MD spends 3 minutes reviewing records/hx
MD spends 5 minutes on exam, then 18 minutes discussing with patient and spouse that she is now considered cured and no longer needs oncology services. Being discharged from specialty care. Recommends routine follow up with PCP and ob/gyn, etc.
MD spends 6 minutes documenting note
Total MD time: 32 minutes = 99214 on time alone

Assume MDM documented is level 2 (stable chronic illness, not ordering additional testing, low mortality/risk). I can HOPE my clinician would document time for this patient, since it was significantly more than usual for straightforward decision making.

For me, in daily E/M coding, I expect to use MDM only on >95% of visits, as I do now (for hx, exam, MDM). Occasionally there will be an unusual situation where the physician spends significant extra time. I have educated the clinicians to be sure to document times in those situations.

Maybe you work for a clinician that spends 20 minutes reviewing 10 years of records prior to each appointment. Or is technology challenged and it takes 5 minutes to order a lab test and 15 minutes to type a note. Or maybe you're pain management and the clinician spends significant time with patients to ensure medication compliance. If that's the case, then your clinician needs to track time and document it. But most clinicians with competent staff or scribes should be able to get a 99214 accomplished with less than 30 minutes of actual MD time.

I'll say it's nice to have the option, but I personally don't expect to use it any more often than I currently use time.
Hi Christine,
Thank you so much for this post it is exactly what I was thinking so it is nice to see someone else agree!
 
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