Wiki Time Based E/M

Deb2009

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When billing for time based E/M, does the documentation first need to meet a 99213 - 99215, and then look at the time or can you go directly to the time that the provider has documented? for example: "Today’s visit was 60 minutes with more than 50% of the total time spent with the patient in counseling and coordination of care." Thank you in advance for your responses.
 
When billing for time based E/M, does the documentation first need to meet a 99213 - 99215, and then look at the time or can you go directly to the time that the provider has documented? for example: "Today’s visit was 60 minutes with more than 50% of the total time spent with the patient in counseling and coordination of care." Thank you in advance for your responses.


Hi,

I've seen both ways done; however when I was taught auditing, my instructor told us to always check the note for the "elements" (history, exam, MDM) level and the time and use which is most advantageous to the provider. Most I have come across have met higher on the time; however I have had a few rare cases where the elements came to higher level and surprisingly without template use but dictated notes.

T
 
Thank you, that is what I what I have done also. We are having discussion that the "elements" must be there 1st and then if time brings it higher then you go with time. I always just 'glance' at "elements" if time is documented! Not sure if that is correct or not? So you are saying that "elements" must be there and then if time takes it to a higher level then you go with time?
 
Thank you, that is what I what I have done also. We are having discussion that the "elements" must be there 1st and then if time brings it higher then you go with time. I always just 'glance' at "elements" if time is documented! Not sure if that is correct or not? So you are saying that "elements" must be there and then if time takes it to a higher level then you go with time?

Not necessarily the elements, but the medical necessity must be. For instance, I work with pediatric specialty groups some of which are more "hands off" than "hands on" meaning their visits are more review of data ordering tests, and not necessarily having information to support HPI on subsequent visits or need to do an exam - such as genetics, hem/onc does a lot of counseling and coordination of care. I've even had cases in urology where the pregnant mother was referred to our pediatric urologist because prenatal ultrasounds showed an issue with the renal system of the fetus and the MD will meet with the mother prior to birth to review films, provide reassurance and/or start a plan of care to address at time of birth so technically the patient was the fetus, but you can't perform an exam on a baby still in the womb :unsure: so the visit was more counseling and coordination of care and billed based off of the time spent with the mother.
 
I forgot to add, don't forget to watch for template of the same time statement repeatedly...especially in regards to the total time and the content of the counseling. I've had to work on that with some of mine.
 
Beverly. The basis answer is no. Time should not be used on every visit. Time based documentation should be used sparingly.
I MOSTLY agree with this. It can vary depending on specialty. There are some specialties that use time based much more than others.
A good example is inpatient palliative care team. They spend a lot of time even for follow up visits because they are discussing plans with patient and family, coordinating the care of several specialists, etc.
But definitely most physicians spend > 50% of their time for each visit counseling and coordination of care for a very small percentage of their patients.
 
I MOSTLY agree with this. It can vary depending on specialty. There are some specialties that use time based much more than others.
A good example is inpatient palliative care team. They spend a lot of time even for follow up visits because they are discussing plans with patient and family, coordinating the care of several specialists, etc.
But definitely most physicians spend > 50% of their time for each visit counseling and coordination of care for a very small percentage of their patients.
I totally agree with you. There are specialties where time based coding is much more common. But generally speaking for most specialties...
 
As far as I'm aware of, there hasn't been any official guidance from CMS or other sources that states that time cannot be used on all visits or that it should be limited or restricted in any way. In fact, the proposed changes to E&M documentation for 2021 would give physicians the choice between using either time or MDM for the selection of the office E&M levels for all visits, and would eliminate the requirement that greater than 50% be spent in counseling or coordinating care, so they are actually expanding their allowance for it rather than reducing it.

In my experience working in payer audits, the only occasions where I saw payers questioning the use of provider time for coding were in cases where providers were fraudulently billing more time-based services than there were hours in the work day, which obviously is something that will cause a provider to appear as an outlier and create a red flag to payers to look more closely at their claims.
 
As far as I'm aware of, there hasn't been any official guidance from CMS or other sources that states that time cannot be used on all visits or that it should be limited or restricted in any way. In fact, the proposed changes to E&M documentation for 2021 would give physicians the choice between using either time or MDM for the selection of the office E&M levels for all visits, and would eliminate the requirement that greater than 50% be spent in counseling or coordinating care, so they are actually expanding their allowance for it rather than reducing it.

Thomas, you missed the point. No one is saying that time should be restricted per CMS or other guidelines rather than the three key components. And time will still be used in 2021. Let's look at an example. If a physician billed out a 99214 on every patient, that would be a red flag. However, Geriatric providers bill out 99214 on virtually every patient, every visit, but it is expected because of the type of patient they are seeing. The top of the bell curve for an orthopedic physician is 99203. If you see an otho where that is not the case, chances are they are not billing correctly or over documenting. An experienced internal medicine physician can reach a 99214 in less than ten minutes and coding by time would not benefit them. All that we were saying is that the percentage of coding based on key components vs time is going to change depending on the specialty of the physician. And you would totally expect that. I am very pleased that CMS will be changing to time and MDM making next year. This is long overdue. EMR's basically guide the medical staff to document a comp history on every patient, which is not medically necessary. So in the world that we live in today, the key components documented, generally speaking, do not meet medical necessity. I'm looking forward to 2021.
 
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When billing for time based E/M, does the documentation first need to meet a 99213 - 99215, and then look at the time or can you go directly to the time that the provider has documented? for example: "Today’s visit was 60 minutes with more than 50% of the total time spent with the patient in counseling and coordination of care." Thank you in advance for your responses.
When billing for time based E/M, does the documentation first need to meet a 99213 - 99215, and then look at the time or can you go directly to the time that the provider has documented? for example: "Today’s visit was 60 minutes with more than 50% of the total time spent with the patient in counseling and coordination of care." Thank you in advance for your responses.

thank you this was very helpful
 
Thomas, you missed the point. No one is saying that time should be restricted per CMS or other guidelines rather than the three key components. And time will still be used in 2021. Let's look at an example. If a physician billed out a 99214 on every patient, that would be a red flag. However, Geriatric providers bill out 99214 on virtually every patient, every visit, but it is expected because of the type of patient they are seeing. The top of the bell curve for an orthopedic physician is 99203. If you see an otho where that is not the case, chances are they are not billing correctly or over documenting. An experienced internal medicine physician can reach a 99214 in less than ten minutes and coding by time would not benefit them. All that we were saying is that the percentage of coding based on key components vs time is going to change depending on the specialty of the physician. And you would totally expect that. I am very pleased that CMS will be changing to time and MDM making next year. This is long overdue. EMR's basically guide the medical staff to document a comp history on every patient, which is not medically necessary. So in the world that we live in today, the key components documented, generally speaking, do not meet medical necessity. I'm looking forward to 2021.
thank you this was very helpful
 
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