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Time doesn't support level selected

agoad0004

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Hello!

I have a question.... 99215 was billed (documentation supports this code), but only 25 minutes (>50% counseling was spent with the patient). I understand that a provider can select a higher level of service when time is documented... but can time spent lower the billed service to a 99214? Or does documentation trump time in this situation?

Thanks!

Amber Wisdom CPC, CBCS
 

CodingKing

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Hello!

I have a question.... 99215 was billed (documentation supports this code), but only 25 minutes (>50% counseling was spent with the patient). I understand that a provider can select a higher level of service when time is documented... but can time spent lower the billed service to a 99214? Or does documentation trump time in this situation?

Thanks!

Amber Wisdom CPC, CBCS
Time w/ more than 50% counseling/care coordination OR based on the three key components whatever is highest. Anything else would be considered downcoding.
 

Pathos

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I agree with CodingKing, however don't forget to have the provider add a brief summary of what was being counseled.

Per CMS E/M guidelines:

"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."

Determine the E/M level based on E/M elements, or when Time has been properly documented. Medical Necessity always trumps anything else though, despite any points or bullets assigned in an audit tool, however they usually go hand-in-hand.

So in the example given, since documentation supports (and hopefully medical necessity) 99215; you should be able to bill a 99215 despite time suggests a 99214.


Hope that helps!
 

Pathos

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Pathos - do you have a reference link to your statement "Medical necessity trumps anything else" with regards to qualifying for a particular level of E&M service? I was taught this as well, but my employer says based on DG "time is considered the key controlling factor when counseling &/or coordination of care dominates more than 50%...)". I need a source document that states medical necessity is the overarching criterion in Level of Service Selection. Thank you!
Good morning McDream,

Sure, here is a link from my local MAC, which in turn has a link to some CMS Manuals:

https://med.noridianmedicare.com/web/jfb/cert-reviews/mr/documentation

That should get you the references you need.
 

cgaston

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https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r178cp.pdf

Per page 2, time is only a factor if more than 50% of the time is spent counseling or coordinating care:

Instruct physicians to select the code for the service based upon the content of the service. The duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for noninpatient services) or more than 50 percent of the floor time (for inpatient services) is spent providing counseling or coordination of care as described in subsection C.


In my quick search I found that History, Exam and MDM should all be considered when determining the level of E&M. However, my company has a policy that we consider the MDM when deciding on a code level, so the policy could be employer specific and that is why we cannot find anything on the web.
 
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Pathos

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CMS Claims Manual 12;30.6

"Medical necessity of a service is the overarching criterion for payment in addition to the
individual requirements of a CPT code. It would not be medically necessary or
appropriate to bill a higher level of evaluation and management service when a lower
level of service is warranted. The volume of documentation should not be the primary
influence upon which a specific level of service is billed. Documentation should support
the level of service reported. The service should be documented during, or as soon as
practicable after it is provided in order to maintain an accurate medical record.
"

Another MAC article

AAPC article on the matter too

That is probably the best you will find.
 
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