Using Time to Choose a Non-Office E/M Code
For office and outpatient codes 99202-99205 and 99212-99215, code selection is based on either total time or MDM. If the total time falls in the range in the code descriptor, you may report that code for the encounter. For other E/M codes that include time in their descriptors, coding based on time is more complicated.
In some cases, using time to select a non-office E/M code may result in a higher-level code than using history, exam, and MDM. But you should only use time as the controlling factor in your non-office E/M code selection when counseling, coordination of care, or both make up more than 50% of the face-to-face time with the patient or family or more than 50% of the floor/unit time, depending on the nature of the service.
Counseling is a discussion with the patient, family, or both that covers at least one of the following, according to CPT® E/M guidelines:
- Diagnostic results, impressions, or diagnostic studies recommended for the patient
- The patient’s prognosis
- Treatment options’ risks and benefits
- Instructions regarding treatment or follow-up
- Reasons why complying with the selected treatment or management options is important
- How to reduce risk factors
- Education for the patient and family
For this E/M coding based on time, “family” includes those who are responsible for patient care or decision-making, such as foster parents or a legal guardian. But pay attention to payer rules, which may differ from CPT® guidelines, such as requiring the counseling and care coordination to occur in the patient’s presence.
To support this type of E/M reporting based on time, documentation should include the “extent” of counseling and/or coordination of care, according to CPT® E/M guidelines. The 1995 and 1997 Documentation Guidelines expand on this, stating the provider should document the total length of time of the encounter and the counseling or activities performed to coordinate care. The documentation also will need to show that the encounter exceeded the 50% threshold for time spent on counseling, coordination of care, or both.
In a best-case scenario, documentation of time for an E/M visit should include the following to determine if the counseling and care coordination accounted for more than half the time:
- The beginning and ending time of the counseling and/or coordination of care
- The beginning and ending time for the overall face-to-face or floor/unit service.
The provider also should include the components of history, exam, and MDM — even if cursory — in the documentation. Good medical record keeping requires that the provider document pertinent information. Using time as the determining factor to choose the E/M level does not change that documentation requirement.
Consider this example of coding based on time: A surgeon and patient spend 20 minutes of a 25-minute subsequent inpatient visit discussing test results and treatment options for colon cancer. The surgeon summarizes the discussion in the medical record. The history, exam, and MDM are minimal in this case, but because counseling dominates the encounter, you can use time as the controlling factor when assigning the E/M service level. You should code the visit as 99232 … Typically, 25 minutes are spent at the bedside and on the patient’s hospital floor or unit … based on the 25 minutes documented for the total visit and the percentage of time spent on counseling.
For complete information about reporting E/M based on time, you should check with individual payers to learn if they require you to meet the time stated in the code descriptor or if they allow you to round up to the closest reference time.
If the E/M codes you are choosing from have no reference time, you can’t use time as a controlling factor when determining the appropriate service level.