Wiki Time-Based E/M Documentation

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cbosi1

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Hi. I am wondering if anyone has seen any official guidance on how exactly to document time to justify coding? I have been researching; reading AMA guidelines, CMS guidelines and AAPC articles and forums. Per AMA and CMS, the definition of "Time" in the time-based coding is minimum time; not typical time. One of our providers believes that time should be documented to the exact minute, for example:

"I have personally spent 47 minutes total time today in preparation, patient care, and documentation for this visit, including the following: review of clinical lab tests; review of medical tests/procedures/services."

Currently, we are documenting based on the minimum amount of time for each code. For example:

"I have personally spent 40+ minutes today in preparation, patient care, and documentation for this visit, including the following: review of clinical lab tests; review of medical tests/procedures/services."

I couldn't find anything anywhere that says that documenting as "30+" or "40+" is incorrect. I haven't seen any official guidance that requires the actual times to be listed either. (10:15 - 11:02)

Any thoughts? Thanks in advance.
 
There is no official guidance I am aware of other than if using time, the amount of time must be documented, and information about what was performed during that time.
I personally think "47" is FAR superior to "40+" in documentation. You may come across some carriers or auditors who will find "40+" insufficient documentation of time.
You certainly do NOT need to document as either:
- exact times: 8:10a-8:17a reviewed records, 10:02a-10:33a examined patient and discussed treatment options, 12:02p-12:11p charted and entered orders
- spent 7 minutes reviewing records, 31 minutes examining patient and discussing treatment options, 9 minutes charting and entering orders
But "40+" is just too vague for my comfort level as I consider time to be the actual amount of minutes, not an approximation.
 
I have seen some notes where the provider continues to state the total time, face to face time, greater than 50% spent counseling/coordination of care, etc. As long as they have the total time I think it's okay but it's not necessary to have that specific statement anymore for office/oupatient. It also doesn't make sense to use it and I could see an auditor possibly having a finding or not accepting it. I agree with Christine that a more vague statement of 30+ or 40+ is not ideal, but I probably wouldn't cite that in an audit for office/outpatient as long as the time was stated. I also agree that trying to use the exact times to the minute is not necessary. This differs from auditing/coding for time based codes that require the exact start/stop times and/or are billed in increments of 15 minutes.

https://codingintel.com/time-using-time-for-em-services-in-2021/ (6 minutes addresses this and makes sense)

Basically the statement should not be vague or just say something like "40 minutes". It has to be a statement with information on what was performed, discussed, etc.
I would accept either statement you gave as an example above.
 
cottrellk1 said:
So there is not a required statement for face-to-face time and/or coordination of care? I've been seeing a lot of statements, but for those not using the statement I was trying to find examples to send to my providers. Just curious. Thank you. I am at kimcottrell@hotmail.com
Click to expand...
I haven't seen any official (CMS, AMA, etc) time statement examples. I think there are a lot of possible occasional scenarios where nuances might matter.
For example: time cannot include any separately billed procedures. If a sonogram, EKG, x-ray, sutures, etc. are performed, time spent on that separately billed procedure cannot be counted. Providers who are also performing procedures should word accordingly. In your original examples "patient care" could include time on a separately billed procedure and could be an issue.
In general, if the time seems reasonable for the patient's problems, and nothing else separately billed, then your example would suffice. If there was a patient that time was unusual, then the provider should be more specific to explain the reason. For example - pt is there to discuss MRI of the knee and treatment plan. Clinician explains some minor findings and is recommending PT 3x week for 6 weeks and re-evaluation. Clinician spends 20 minutes. Then patient says "Can you please call my son Steve and go over this with him?" You spend another 12 minutes with Steve and then patient says "You know, I really want my cousin Roger involved in this too." So you call Roger and also go over this with Roger who has multiple questions for another 20 minutes. So what might typically be a 20 minute visit to recommend PT turns into a 52 minute visit. In that scenario, "I have personally spent 52 minutes total time today in preparation, patient care, and documentation for this visit, including the following: review of clinical lab tests; review of medical tests/procedures/services." would be better explained by "I have personally spent 52 minutes total time today in preparation, patient care, and documentation for this visit, including the following: review of clinical lab tests; review of medical tests/procedures/services. At patient's request, I called and spoke with son Steve and cousin Roger to explain the treatment plan which resulted in a longer than usual visit."
The AMA 2021 guidelines state this:
Total time on the date of the encounter (office or other outpatient services [99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215]): For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).

Physician/other qualified health care professional time includes the following activities, when performed:
§ preparing to see the patient (eg, review of tests)
§ obtaining and/or reviewing separately obtained history
§ performing a medically appropriate examination and/or evaluation
§ counseling and educating the patient/family/caregiver
§ ordering medications, tests, or procedures
§ referring and communicating with other health care professionals (when not separately reported)
§ documenting clinical information in the electronic or other health record
§ independently interpreting results (not separately reported) and communicating results to the patient/ family/caregiver
§ care coordination (not separately reported)

Do not count time spent on the following:
§ the performance of other services that are reported separately
§ travel
§ teaching that is general and not limited to discussion that is required for the management of a specific patient
 
csperoni said:
I haven't seen any official (CMS, AMA, etc) time statement examples. I think there are a lot of possible occasional scenarios where nuances might matter.
For example: time cannot include any separately billed procedures. If a sonogram, EKG, x-ray, sutures, etc. are performed, time spent on that separately billed procedure cannot be counted. Providers who are also performing procedures should word accordingly. In your original examples "patient care" could include time on a separately billed procedure and could be an issue.
In general, if the time seems reasonable for the patient's problems, and nothing else separately billed, then your example would suffice. If there was a patient that time was unusual, then the provider should be more specific to explain the reason. For example - pt is there to discuss MRI of the knee and treatment plan. Clinician explains some minor findings and is recommending PT 3x week for 6 weeks and re-evaluation. Clinician spends 20 minutes. Then patient says "Can you please call my son Steve and go over this with him?" You spend another 12 minutes with Steve and then patient says "You know, I really want my cousin Roger involved in this too." So you call Roger and also go over this with Roger who has multiple questions for another 20 minutes. So what might typically be a 20 minute visit to recommend PT turns into a 52 minute visit. In that scenario, "I have personally spent 52 minutes total time today in preparation, patient care, and documentation for this visit, including the following: review of clinical lab tests; review of medical tests/procedures/services." would be better explained by "I have personally spent 52 minutes total time today in preparation, patient care, and documentation for this visit, including the following: review of clinical lab tests; review of medical tests/procedures/services. At patient's request, I called and spoke with son Steve and cousin Roger to explain the treatment plan which resulted in a longer than usual visit."
The AMA 2021 guidelines state this:
Total time on the date of the encounter (office or other outpatient services [99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215]): For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).

Physician/other qualified health care professional time includes the following activities, when performed:
§ preparing to see the patient (eg, review of tests)
§ obtaining and/or reviewing separately obtained history
§ performing a medically appropriate examination and/or evaluation
§ counseling and educating the patient/family/caregiver
§ ordering medications, tests, or procedures
§ referring and communicating with other health care professionals (when not separately reported)
§ documenting clinical information in the electronic or other health record
§ independently interpreting results (not separately reported) and communicating results to the patient/ family/caregiver
§ care coordination (not separately reported)

Do not count time spent on the following:
§ the performance of other services that are reported separately
§ travel
§ teaching that is general and not limited to discussion that is required for the management of a specific patient
Click to expand...
Great feedback!

We could start getting into the weeds for sure and the statement has to be relevant and specific to the situation, totally agree.
Using a blanket statement copied into each note is not a great idea. Also, coding every single visit by time is probably not a great plan either. :)
 
amyjph said:
Great feedback!

We could start getting into the weeds for sure and the statement has to be relevant and specific to the situation, totally agree.
Using a blanket statement copied into each note is not a great idea. Also, coding every single visit by time is probably not a great plan either. :)
Click to expand...
Of course, now I'm really veering into another discussion, but it is my opinion that about 95% of clinicians with appropriately trained staff can provide the MDM level of service required with less physician time than required.
There are a handful of specialties (like palliative care) where time really can be a major component. But if a 99213 requires 20-29 physician minutes, that means in an 8 hour workday, assuming everyone is established level 3, the physician can only see 16-20 patients.
99204 requires 45-59 minutes of physician time. It only requires 2 chronic stable problems and a prescription for 99204 using MDM. Sure, like my example above a 20 minute visit can turn into a 52 minute visit, but those are exceptions. For the rest of your patients, create a workflow that allows your RN, LPN, PA, NP, MA, scribe, etc. to do what they can, with your physician focusing on the actual patient care.
I tell my physicians to document time only if they feel it was an unusually long visit. And even then I almost always get the same (or higher) on MDM.
 
csperoni said:
Of course, now I'm really veering into another discussion, but it is my opinion that about 95% of clinicians with appropriately trained staff can provide the MDM level of service required with less physician time than required.
There are a handful of specialties (like palliative care) where time really can be a major component. But if a 99213 requires 20-29 physician minutes, that means in an 8 hour workday, assuming everyone is established level 3, the physician can only see 16-20 patients.
99204 requires 45-59 minutes of physician time. It only requires 2 chronic stable problems and a prescription for 99204 using MDM. Sure, like my example above a 20 minute visit can turn into a 52 minute visit, but those are exceptions. For the rest of your patients, create a workflow that allows your RN, LPN, PA, NP, MA, scribe, etc. to do what they can, with your physician focusing on the actual patient care.
I tell my physicians to document time only if they feel it was an unusually long visit. And even then I almost always get the same (or higher) on MDM.
Click to expand...
Good point. I agree with you it can be really specialty & sub-specialty specific. Yes, MDM in many cases is the better way to go.
 
If a provider indicates 60 mins total time with the OV, including physical exam was 45 mins and 15 mins of charting/prep, are we giving credit for the full 60 or just 45 (time actually spent with the patient)?
 
Copied from CSperoni's post above:
Physician/other qualified health care professional time includes the following activities, when performed:
§ preparing to see the patient (eg, review of tests)
§ obtaining and/or reviewing separately obtained history
§ performing a medically appropriate examination and/or evaluation
§ counseling and educating the patient/family/caregiver
§ ordering medications, tests, or procedures
§ referring and communicating with other health care professionals (when not separately reported)
§ documenting clinical information in the electronic or other health record
§ independently interpreting results (not separately reported) and communicating results to the patient/ family/caregiver
§ care coordination (not separately reported)
 
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