Documentation Billing E/M based on time

Merlin0728

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We have a provider that would like to bill based on time. He documented the following in his note.

"Appointment billed for 1 hour, the majority obtaining history and trying to clarify her understanding, and whether she did have cancer, etc."

Does anyone have an opinion on whether his documentation meets the criteria for the coding guidelines?

“In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility). Time is considered the key or controlling factor to qualify for a particular level of E/M services."

Thank you!
 

pscanlan

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I am not familiar with the source you quoted. I have always been told (and I believe the front of the CPT book states) that time is not the basis for determining which level of E/M was performed. Rather, the number of systems reviewed, the complexity of medical decision making, and the severity of the presenting illness were the determining factors. I would not want to face an audit of a physician basing his E/M billing on time alone.

I have, however, encountered physicians who billed a G code (the specific code is slipping my mind) for additional counselling above and beyond what would be included in the appropriate E/M. There are specific codes for smoking cessation counselling and I think a few other specific categories of face-to-face time. Perhaps you could look into these as an alternative to upcoding this physician's E/M codes.

Edit: So I found your quote. For those following along at home, this: “In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility). Time is considered the key or controlling factor to qualify for a particular level of E/M services." is from page 10 of the 2019 AMA CPT manual, just at the end of the E/M guidelines.

In the context of that page of the guidelines the quote doesn't make much sense. I mean it directly contradicts the previous two points, namely 1) all key components must meet or exceed the levels for one subset of E/M codes 2) that two of three key components must meet or exceed the levels for another subset of E/M codes. They do not then list a subset of E/M codes to which this counselling/COC exception applies.

I've never heard of this rather large exception to the E/M rules, despite the fact that it's in the front of the CPT book. If anyone has some guidance on why this comes off as contradictory, I'm all ears.

Returning to your actual question, whether or not that one line of text is enough to justify billing for 99205, 99220, etc because those are closer to the time spent, I would tend to think no. That one line describing the encounter does not satisfy the requirement that "The extent of counselling and/or coordination of care must be documented in the medical record." Now if there's a whole H&P in the medical record... maybe. I still don't like the idea that we've thrown out the medical decision making, data to be reviewed, and other components of the E/M simply because this is a counselling visit, but if there's documentation of the counselling (one line does not a document make) then I could understand billing for his time.
 
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Pathos

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Per CMS E/M guidelines:

"LEVEL OF E/M SERVICE PERFORMED
The code sets to bill for E/M services are organized into various categories and levels.
In general, the more complex the visit, the higher the level of code you may bill within the
appropriate category. To bill any code, the services furnished must meet the definition of
the code. You must ensure that the codes selected reflect the services furnished.

The three key components when selecting the appropriate level of E/M services provided
are history, examination, and medical decision making. Visits that consist predominately
of counseling and/or coordination of care
are an exception to this rule. For these visits,
time is the key or controlling factor to qualify for a particular level of E/M services.

Documentation of an Encounter Dominated by Counseling and/or Coordination of Care

When counseling and/or coordination of care dominates (more than 50 percent of) the
physician/patient and/or family encounter (face-to-face time in the office or other outpatient
setting, floor/unit time in the hospital, or NF), time is considered the key or controlling
factor to qualify for a particular level of E/M services. If the level of service is reported
based on counseling and/or coordination of care, you should document the total length
of time of the encounter and the record should describe the counseling and/or activities
to coordinate care.
"


The example shown does not indicate that the visit was predominately spent on counseling and coordination of care, however was perhaps split up in
"obtaining history and trying to clarify her understanding, and whether she did have cancer, etc."
If I was to audit that example, I would not accept time as the overriding factor, based on the CMS guidelines I have provided. Also, there is some reference (which I don't have handy right now) that indicates that the "Greater than 50% of the time spent" cannot include time spent on History collection, or Exam performing, but exclusive to the patient counseling and coordination of care.


Hope this is helpful!
 

mitchellde

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The way I was taught way back in the day is this.. To determine if time dominates the encounter you must first determine the visit level based on the 3 key components. there must also be a time statement of the total time invested in the visit and whether more than 50 % was spent counseling. for instance a 1 hour visit that has the three key components of a 99213 but documented as 1 hour. to up code the visit you must have the greater than 50 % statement. and you can see that this is a true statement. I like to use prolong time personnaly when the time is met. in this case you have 45 minutes after the 3 key components so I would use the 99213 and the 99354. it has always worked better for me to it that way.

But here is another theory, since the 99211 has no components that must be met, you can always say that a visit with none of the three components but with a tine statement of greater than 50% could always be coded by time as long at it is at least 11 minutes. I don't know that I would necessarily subscribe to this theory but I know someone that does document in a fashion where they code this way. They are certain they could win every audit if need be.
 
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