billing based on time


East Haven, Connecticut
Best answers
If a physician bills for an established patient visit, based on time, what would the correct code be if he spent 35 minutes with the patient in counseling?

Would you bill for a 99215, which is 40 minutes? Or would you bill a 99214, which is 25 minutes? The CPT states "typically spends" for time, so is this up to the physician to choose?
You will have to select the 99214. The time can exceed but you can not upcode if it is under. Even if the provider documented 39 minutes you still can only bill the 99214.
Per CPT "It should be recognized that 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". So, yes, I think it is up to the physician. I have never heard of the previously stated guideline regarding 39 minutes...

The times are qualified as averages which "may be higher or lower" because a most physicians do not bill based on time, but rather based on hitting the required bullet point of history, exam, decision making.

However, if you are billing based on time spent, your documented time must equal or exceed the "average" time given to bill that level. AND you bill based on TOTAL time spent (not just the amount of time spent in counselling)

Also, your documentation must state
1) total time spent face-to-face
2) amount of time spent in counselling/coordination of care (must be more than 50% of total time)
3) basic statement of extent of counselling.

E.g. I spent 35 minutes with patient, 20 minutes of which was for counselling regarding weight management, helping to formulate a diet and excercise plan.
This would be a 99214.

If your physician spent a total of 40 minutes with the patient, 35 minutes of which was counselling ... then the TOTAL time spent would equal a 99215.

F Tessa Bartels CPC, CPC-E/M