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Coding based on time

kfenton

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South Windsor, CT
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A physician in my practice has documentation that supports CPT 99214, however at the end of his note, he documents that he spent a total of 50 minutes with the patient and of that time 50% was spent counseling/coordinating care. Based on time, CPT 99215 would be appropriate. Does the HPI, Exam and MDM documented supercede the time documented or vice versa? And where can I find a reputable source (ie Medicare) to prove the correct answer?
 

dmaec

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kfenton -
If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diaganosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider. 3 questions should be asked when coding based on time:
1) Does documentation reveal total time? (face to face in outpatient setting) (unit/floor in inpatient setting)
2) Does documentation describe the content of counseling or coordinating care?
3) Does documentation reveal that more than half of the time was counseling or coordinating care?

the answer needs to be yes to all three questions in order to correctly code based on time.

Notice, it needs to be MORE than 50% of the time AND it documentation needs to state the counseling and cooridinating - not just a final line of "50 minutes spent with patient of which more than half was spent in counseling or cooridinating care" ...

{that's my opinion on the posted matter}

(sorry, can't find my link for this but it was from CMS Medicare Part B)
 

RebeccaWoodward*

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EXAMPLE 3
A physician provided a subsequent office visit that was predominantly counseling, spending 60 minutes (face-to-face) with the patient. The physician cannot code 99214, which has a typical time of 25 minutes, and one unit of code 99354. The physician must bill the highest level code in the code family (99215 which has 40 minutes typical/average time units associated with it). The additional time spent beyond this code is 20 minutes and does not meet the threshold time for billing prolonged services.

http://cms.hhs.gov/mlnmattersarticles/downloads/mm5972.pdf
 
Messages
4,466
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Milwaukee WI
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Only 99214

The physician has documentation to meet 99214. Done deal.

The physician also notes 50 minutes spent w/ patient, 50% in C&C.
As Donna previously mentioned, you can't use this to code up to 99215, because he didn't spend more than 50% of the time in C&C.

You also cannot use time to bill prolonged services, because 99214 has an average time of 25 minutes. 50 minutes total less 25 minutes is just 25 minutes, and you need at least 30 minutes to bill 99354.

So all you have is your established office visit, 99214.

Rebecca ... your example is great if you were trying to bill the entire visit based on time (C&C). However, if the documentation fully supports a certain level (can even be level 1), and your time spent with the patient face-to-face is at least 30 minutes beyond the average time for the documented level of E/M, you can use the prolonged service code.

F Tessa Bartels, CPC, CPC-E/M
 
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RebeccaWoodward*

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and Tessa...you are correct. I don't disagree with these statements. My intention was to point out the appropriate way to bill. Since I did not elaborate... it did leave a margin of question. That's what I get for assuming. You know that they say about that...I won't go there. Thanks for reminding me that I need to complete my thoughts.
 
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