Wiki Time in E/M coding

[jessicahocker]

I went to a conference recently where I was told in an E/M panel Q&A that a statement after the Discussion portion of the note stating "31 minutes of the 60 minute visit spent in coordination and counseling of care" was not adequate to code on the basis of time, even if the Discussion documented what was talked about. My coworker disagrees, as the information is stated in the Discussion. Guidance?

I was also told during this panel that even if Time is documented correctly, the medical decision making and complexity should determine the correct level, not the documentation itself. Help?

Citations are always appreciated. I have only been coding for 6 months, so your input is valued. Thank you.

 

[CodingKing]

I don't think they completely know what they are talking about. Its right in the 1995/1997 E&M Documentation Guidelines that Time can be the controlling factor. Although the statement of time spent is only part of the equation. There must be documentation of what was done during the counseling and care coordination



D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY
COUNSELING OR COORDINATION OF CARE
In the case where counseling and/or coordination of care dominates (more than 50%) of
the physician/patient and/or family encounter (face-to-face time in the office or other or
outpatient setting, floor/unit time in the hospital or nursing facility), time is considered
the key or controlling factor to qualify for a particular level of E/M services.
DG: If the physician elects to report the level of service based on counseling
and/or coordination of care, the total length of time of the encounter (faceto-face
or floor time, as appropriate) should be documented and the
record should describe the counseling and/or activities to coordinate care.

1995 Guidelines
https://www.cms.gov/Outreach-and-Ed...N/MLNEdWebGuide/Downloads/95Docguidelines.pdf

1997 Guidelines
https://www.cms.gov/outreach-and-ed...n/mlnedwebguide/downloads/97docguidelines.pdf

 

[mhstrauss]

I agree with CK. The '95/'97 DG are the place to go for E/M citations; similar time statements can also be found in the CPT book. You can also check with your MAC; they may have FAQ's about this that will further clarify. Was this panel for a particular payer that has their own guidelines maybe?

 

[thomas7331]

I imagine that they are talking about medical necessity, not medical decision making. As is so frequently quoted from CMS guidelines: "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." This guideline would apply to time-based coding as well as to coding by the elements. So, for example, a stable and asymptomatic patient or patient with a minor issue would not warrant a 99205 even if the provider did spend 60 minutes their time. The documentation of the nature of the presenting problem needs to show that there was a valid medical need for that time.

 

[CodingKing]

I wasn't even thinking of them referring to Medically Necessary and not MDM. Correct if you are doing a 60 min appointment and all that care coordination for the common cold there would be an issue there.

 

[wbradhoward]

Documentation requirements when billing based on time

I went to a conference recently where I was told in an E/M panel Q&A that a statement after the Discussion portion of the note stating "31 minutes of the 60 minute visit spent in coordination and counseling of care" was not adequate to code on the basis of time, even if the Discussion documented what was talked about. My coworker disagrees, as the information is stated in the Discussion. Guidance?

I was also told during this panel that even if Time is documented correctly, the medical decision making and complexity should determine the correct level, not the documentation itself. Help?

Citations are always appreciated. I have only been coding for 6 months, so your input is valued. Thank you.

Jessica,

The only deficiency that I see in the above time statement is the lack of documentation that the total time was face-to-face time. I think that the fact that they are using an actual number (31 minutes) is completely appropriate as it is greater than 50% of the total time, but that total time needs to be specified as face-to-face time with the patient.

I would suggest the following verbiage to remove all doubt: "60 minutes was spent face-to-face with the patient, 31 minutes of which was spent in counseling and coordination of care with regards to the patient's illness and options for treatment, etc. etc." It is important that the provider documents the nature of the counseling/coordination of care, and it is this element that is most often missed when documenting time.

As long as these criteria are met, the time should trump the individual elements that are normally calculated to determine the level of service (e.g. history, exam and MDM). It is also important to note that if the calculations of history, exam and MDM support a higher level of service than the time statement does, you can still bill the higher level - in other words the provider won't be penalized for efficiency. Time trumps Hx, Exam and MDM only when it elevates the level of service, it won't ever bring a level down.