Wiki Time based coding

[Tricia13]

I understand that the time associated with any given code is considered the most conservative. Given that, can the providers use a 99215 for 33 minutes, for example, or does the provider need to have at least 40 minutes?

Let me clarify my question, and thank you for your responses. If the provider is using time as the determining factor does, for example, if he does 33 minutes would that be the threshold for a 99215 based on time with more than 50% in counseling and coordination of care? Or, would he need exactly 40 minutes and no less?

 

[mitchellde]

The visit level is based first and foremost on the three key components of History, exam, and decision making. The time given in the book is the average amount of time the AMA considers necessary to perform that level of exam. Your physician may do it in more time or less time as long as the documentation meets the criteria of the 3 key components for a 5 then that is the level.

 

[wbradhoward]

I agree with above reply - I would add that if the provider does spend 40 minutes with the patient, you can then bill for a level 5 even if the history, exam and MDM dont meet the criteria for the higher level of service.

 

[mitchellde]

To extend Brads response if I may... provided that the visit is 50% or more in counseling and time is documented by the physician.

 

[FTessaBartels]

More than half the difference

When using time for counseling/coordination of care to determine the level of the visit you may code to the higher level IF the time recorded is more than half the difference between the lower code and the higher code.

Wow ... that sounds confusing even to me.

Okay. I'll try to make the math simple.

99215 is typically 40 minutes
99214 is typically 25 minutes
The difference is 15 minutes.

You divide the difference in half - 7.5 minutes rounded up to 8 minutes.
If you have spent 8 or MORE minutes over the 25 minutes, but still not at 40 minutes, you can still code the 99215 based on time spend in counseling/coordination of care.

I recommend you do the math on all the E/M codes that have a typical time and keep that handy.

F Tessa Bartels, CPC, CEMC

 

[wbradhoward]

Yes, sorry - if > 50% is spent in counseling/coodination of care - I agree.

When using time for counseling/coordination of care to determine the level of the visit you may code to the higher level IF the time recorded is more than half the difference between the lower code and the higher code.

I did not know this, however. I have always thought that you had to reach the time in order to use that E/M level - for instance 39 minutes (>50% COC)would only justify 99214, you would need 40 or more to justify 99215. I would be interested/grateful if you could direct me to where this is explained like this?

 

[FTessaBartels]

CPT Assistant

CPT Assistant, August 2004 / Volume 14, Issue 8

On page 3 of this issue: "In selecting time, the physician must have spent a time closest to the code selected. For example, 99214 has a typical time of 25 minutes and 99213 has a typical time of 15 minutes. If the face-to-face office time is 21 minutes, code 99214 would be selected as it is more than half of the time difference."

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[andthomas]

Need TO SPEED UP!!!!!

COULD anyone give me pointers on paceing yourself when taking the test for cpc? i ran out time and had to bubble in the remaining of the time please help any suggestion will be helpful.. please please!!!!!....Drea

 

[Pam Warren]

The visit level is based first and foremost on the three key components of History, exam, and decision making. The time given in the book is the average amount of time the AMA considers necessary to perform that level of exam. Your physician may do it in more time or less time as long as the documentation meets the criteria of the 3 key components for a 5 then that is the level.

We've got two issues here..... The point of using time for coding is that occasionally, your documentation does not meet the key components, so that time is the determining factor. There does need to be medical necessity for coding based on time, but the key components do not need to be taken into consideration if time is documented correctly. The note must state total time and that >50% of this time is spent in counseling and coordination of care. Face-to-face time is important in the office/outpatient setting; in the inpatient setting, floor time can be considered. If the provider only states that he spent 45 minutes with the patient, you may not use time, and you must use key components.

For example, in an office setting, the provider may not document or perform a history or exam, but may spend an hour in discussion of the end-of-life care for the patient. If documented as such, "I spent 60 minutes face-to-face with the patient and his wife; greater than 90% of this visit was spent counseling the patient regarding surgical and medication options, and answering his questions". There is no need to meet key components, based on time, this can easily be coded to a 99215, for an established patient. If the doctor indicated that "I spent an hour with the patient today", then you could only code based on key components. In fact, the time doesn't translate into any auditable factor within any E&M auditing template that I've seen, without also stating counseling/coordination of care.

 

[ajfreeba]

Medicare Rule and AMA History on the Subject

While the clarification below is wonderful, and accurate for Non-Medicare payors, I would like to interject the following when reporting E/M services to Medicare based on time.

Medicare considers the times associated with E/M codes "Threshold" times. We must, of course, consider the context of that which I am about to quote.

Medicare chose to give the following information while describing the addition of prolonged services codes to a claim containing an E/M service based on time. Note, however, that this statement reveals their philosophy in regard to the question at hand:

"Medicare Claims Processing Manual

Chapter 12 - Physicians/Nonphysician Practitioners

30.6.15.1 - Prolonged Services With Direct Face-to-Face Patient Contact
Service (Codes 99354 - 99357) (ZZZ codes)

(Rev. 1875, Issued: 12-14-09, Effective: 01-01-10, Implementation: 01-04-10)

"H. Prolonged Services Associated With Evaluation and Management Services Based on Counseling and/or Coordination of Care (Time-Based)

"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.

"In those evaluation and management services in which the code level is selected based on time, prolonged services may only be reported with the highest code level in that family of codes as the companion code."

So, for Medicare, though total time may be approximated, the documented "approximation" should exceed the "typical/average" time associated with any code you select for payment.