Wiki E/M Codes based on time rounding up times, CPT vs Medicare Rules

[njense]

Hello,

CPT rules will allow rounding up when time is the controlling factor, for instance, patient seen for 20 minutes with >50% counseling could be billed as 99214 even though the time value for 99214 is 25 minutes. I have read articles that state rounding up of times is not allowed by Medicare however I cannot find this stated in any regulations. Does anybody know where this stated?

Thank-You,
Nancy Jensen, CPC
PHMG Waukesha, WI

 

[thomas7331]

The only place I know of where this is stated is in the Medicare Claims Processing Manual, Chapter 12, section 30.6.15.1, linked below. Although that particular section deals mainly with the use of prolonged services codes, it does explicitly state that E&M codes should not be rounded up when using time to report the level:

"When an evaluation and management service is dominated by counseling and/or coordination of care (the counseling and/or coordination of care represents more than 50% of the total time with the patient) in a face-to-face encounter between the physician or qualified NPP and the patient in the office/clinic or the floor time (in the scenario of an inpatient service), then the evaluation and management code is selected based on the typical/average time associated with the code levels. The time approximation must meet or exceed the specific CPT code billed (determined by the typical/average time associated with the evaluation and management code) and should not be “rounded” to the next higher level."

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

 

[kroemer4]

Rounding Up E/M

I have never encountered an instance where an office visit E/M code could be rounded up to support a higher-level code, via CPT or Medicare. There are certain time-frame codes where a range of minutes are included in each level of visit, but that is not the case with 99201-99215. From the auditor perspective, a 99214 that wasn't met by the elements and only had 20 minutes of time documented would be counted as an error. The time documentation would support a 99213.