Compliancy- time based billing

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Does anyone know of CMS link that describes how often you are allowed to/or how much of a provder's care, as a whole, should be time - based billing? is there a % or more info on this? IE: If a provider solely bills based on time for EVERY visit - what specific compliancy issues or regulations are there with that?
 

thomas7331

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There are no limits that I'm aware of. In the past, CMS has actually encouraged providers to bill based on time more often. If the provider wishes to bill 100% of their visits based on time, then there should not be a problem with this, unless they are billing an excess of visits that would suggest to a payer that they are billing for more hours than they could possibly have spent with patients (e.g. billing for more than 24 hours of visit time in a given day). However, even that could conceivably be possible if an MD is supervising mid-level providers working 'incident to' in the office.
 

OpenClaims

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Providers billing solely based on time is perfectly okay. If there is time present that supports a higher level than the MDM would without the time, then you'll want to use the time as your level.

Example: Provider orders a 99213, but documents 50 minutes of time. You can now use the 50 minutes to code a 99215.
Example (2): Provider does not document time and the visit supports a 99214, then you have to code from the visit's MDM.

I would only see a flag potentially coming up if there is a certain provider who is consistently documenting time that would allow for numerous 99215 or 99205's to be billed. Obviously these are possible, but many of them in a row over time may cause a flag.
Does anyone know of CMS link that describes how often you are allowed to/or how much of a provder's care, as a whole, should be time - based billing? is there a % or more info on this? IE: If a provider solely bills based on time for EVERY visit - what specific compliancy issues or regulations are there with that?
 
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Jacksonville, FL
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Providers billing solely based on time is perfectly okay. If there is time present that supports a higher level than the MDM would without the time, then you'll want to use the time as your level.

Example: Provider orders a 99213, but documents 50 minutes of time. You can now use the 50 minutes to code a 99215.
Example (2): Provider does not document time and the visit supports a 99214, then you have to code from the visit's MDM.

I would only see a flag potentially coming up if there is a certain provider who is consistently documenting time that would allow for numerous 99215 or 99205's to be billed. Obviously these are possible, but many of them in a row over time may cause a flag.
I would add that the actual time involved in a visit is documented: 2:15 PM-2:25 PM. I would be very reluctant to simply rely on documentation that states, "Ten minutes spent with patient," or "55 minutes spent with patient."
 

csperoni

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I would add that the actual time involved in a visit is documented: 2:15 PM-2:25 PM. I would be very reluctant to simply rely on documentation that states, "Ten minutes spent with patient," or "55 minutes spent with patient."
For outpatient, since 1/1/2021, the clinician may count all time spent on the visit the day of the encounter, not just the time with patient.
Something like: A total of ## minutes was spent on this visit reviewing previous notes, counseling the patient on <topics>, ordering tests, and medications, and charting.
If you have clinicians who spend a "suspicious" amount of time on fairly simple visits, they would serve themselves well to get a little more detailed. For example, if during the visit, the patient called her son on her cell phone and asked you to speak with him and explain everything to him again, and then did the same with her daughter, that could explain why you spent 52 minutes on a visit to slightly adjust a blood pressure medication.
I have not seen any official guidance that requires the actual times listed.
 
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our internal audited stated that ALL our providers billed EVERY visit on time- and CMS states that as a red flag- so are we safe to saw as long as documention supports time spent its ok? Even if its for every single visit?
 

csperoni

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There is nothing prohibiting billing every visit based on time.
It's one of those situations where it does make something look suspicious, and an insurance audit may look a little more carefully at anything suspicious. But suspicious is not the same as incorrect. As long as the times are documented, and accurate, then there is nothing to be concerned about.
I'm curious to know where you read that CMS states billing on time is a red flag.
 

Orthocoderpgu

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our internal audited stated that ALL our providers billed EVERY visit on time- and CMS states that as a red flag- so are we safe to saw as long as documention supports time spent its ok? Even if its for every single visit?
Prior to the 2021 E/M documentation change counseling the patient had to be >50% of the visit. And yes, if you had a provider that always billed based on time, it would be a red flag since not every visit would require counseling. With the new guidelines the providers are now allowed to base their E/M level on time alone and counseling is not a requirement. As Christine points out, if everything is accurate there should be no reason for concern.
 

amyjph

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Agree with all the advice above. Prior to 2021 billing every visit based on time "could" have been seen as a red flag because of the requirement for greater than 50% of the visit spent on counseling/coordination of care and the total time plus counseling & coordination time needing to be documented. Also, as Thomas pointed out, if the total time documented by one provider (without mid-levels incident-to) was excessive or overlapping for a date of service it could be seen as a red flag.

In office/other outpatient 2021 and later it is completely fine to bill every visit based on time if desired. That's one of the main points of the changes.

This is not true for ED, IP, Consults & Observation though. So you have to remember what guidelines you are using.
 
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There is nothing prohibiting billing every visit based on time.
It's one of those situations where it does make something look suspicious, and an insurance audit may look a little more carefully at anything suspicious. But suspicious is not the same as incorrect. As long as the times are documented, and accurate, then there is nothing to be concerned about.
I'm curious to know where you read that CMS states billing on time is a red flag.
Christine, I am being audited bty Blue Cross of MS, and they are stating that we are upcoding for E&M codes. They are changing ALL of our 99205 codes to 99203 and all of our 99215s to 99213. The provider documents all info in the note and then at the end she states: 65mins. Does BCBS have the right to do this?
 

csperoni

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I would first check your contract. I will almost guarantee they are allowed to audit you. Most contracts should provide a way to dispute this type of situation.
This is something you need to take up with the payor.

Regarding the coding...
Does the note just state literally "65mins" without any further context or explanation? Depending on the type of provider, and the complexity of the patient, 65 minutes seems like a bit of a lengthy time for one patient in most situations.
For example, if the patient is coming for BP check and renewal of meds without any other significant issue and the note states 65 minutes, I would find that very unusual. For unusual situations, the documentation should explain why 65 minutes were needed. If they audited 10 charts for patients presenting for BP med renewal and they all said 65 minutes without any explanation or justification, that might be an explanation of why they are downcoding.
 

TThivierge

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Hello AMorgan0502,
At one of my hospital's clinics coded for and worked at docs told never used CPT 99215 unless pt is sent to the EMR immediate for admission. Or the patient is very ill equalizing to a comprehensive exam of moderate high complexity. This means high risk situation with modifying factors, and multiple dx problems or over 40 minutes of time.
I hope this helps understand CPT 99215 usage
Lady T :)
 
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