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Billing based upon time: round up/down?

  1. #1
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    Rose City (Portland, Oregon)
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    Default Billing based upon time: round up/down?
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    Do you consider the time associated with an E&M code to be the minimum to meet or do you round up/down? For example, if a physicians spent 35 min with a patient, would you bill 99214 or 99215?

    Thanks!

  2. #2
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    Tacoma, WA
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    Quote Originally Posted by andersee View Post
    Do you consider the time associated with an E&M code to be the minimum to meet or do you round up/down? For example, if a physicians spent 35 min with a patient, would you bill 99214 or 99215?

    Thanks!
    Unless the physician documented the Time element in the notes, I would not use this for determining either code. The codes need to meet the key components of History, Exam and Medical Decision making. Time is only used if it is documented as a physician face-to-face encounter that is more than 50% of the entire visit. Then you could use the estimated times to determine which way the code should go.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. Default
    If documentation shows total time spent 35 minutes and half of more of the total time was spent counseling about for example mental condition with provider recommendations (provider documentation need to show in details) to improve the problem.
    And i would use 99214 not 99215.
    I hope this help!

  4. #4
    Location
    Milwaukee WI
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    4,466
    Default Counseling/Coordination of Care
    Assuming your documentation meets the requirement for choosing a level based on time spent in counseling/coordination of care ...

    35 minutes would be coded as 99215. We round up when the time spent is closer to the minimum for the next higher code (i.e. 33 min or more for established patient = 99215).

    I asked our Compliance Dept about this some years ago. I can't lay my hands on the specific email any longer, but they had received this guidance at a national conference. It was in keeping with CPT protocol for rounding up on other time-based codes. (e.g. first hour of critical care is 30 min - 74 min).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. #5
    Location
    Tacoma, WA
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    Quote Originally Posted by andersee View Post
    Do you consider the time associated with an E&M code to be the minimum to meet or do you round up/down? For example, if a physicians spent 35 min with a patient, would you bill 99214 or 99215?

    Thanks!

    Just found an article from the Coding Edge Feb 2010 by John Verhovshek, MA, CPC regarding time:

    "Time Reference are Crucial

    Only those E/M services with a time reference may be reported using time as the key component. The time reference is stated in the final sentence of the CPT® E/M code descriptor. For instance, consider the descriptor for new patient outpatient service 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. Note that it specifies, “Physicians typically spend 30 minutes face-to-face with the patient and/or family.” In contrast, according to CPT® guidelines, “Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity bases.” Likewise, observation codes 99234-99236 do not have a time reference. Because these services do not include time references, you should not report them with time as the controlling element.

    With regard to time references, CPT® explains that “specific times expressed in the visit code descriptors are averages and, therefore, represent a range of times that may be higher or lower depending on actual clinical circumstances.” In other words, not every level III, new patient, outpatient service (99203, as described above) will last 30 minutes. Conservative coding suggests the stated time reference is the minimum necessary to report a service by time. For instance, to report 99203, the visit would be at least 30 minutes, with at least 16 (50 percent or more) spent on face-to-face counseling and coordination of care. To report a level IV, new patient, office visit (99204) by time, the visit would need to last at least as long as the stated time reference of 45 minutes, and so on, as shown in Table A.

    Note that time spent taking the patient's history or performing an examination does not count as counseling time
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  6. #6
    Location
    Ellenville, New York
    Posts
    1,176
    Default Consistency
    I have read the article that Arlene referenced before and have also heard Tessa's viewpoint expressed before. I have also seen audits work both ways, but there has always been one key point - be CONSISTENT. If you round up for a few patients when first using time, then always round up. If you must meet the 30 minutes for level 3, then use that criteria for all patients.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  7. #7
    Location
    Boise, Idaho
    Posts
    424
    Default
    From the Coding Institute
    December 2011, Vol. 13, No. 12 (Pages 81-88)

    “There are only two ways that you can use time as a basis for
    selecting an E/M code,” says Barbara J. Cobuzzi, MBA,
    CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of
    CRN Healthcare Solutions, a consulting firm in Tinton Falls,
    N.J. “If counseling/coordination of care takes up 50 percent or
    more of the visit, and if the code has a typical time associated
    with it. So by these codes now having a time reference, it
    sounds like we may have a way to reference time used if
    counseling or coordination of care takes up at least 50 percent
    of a visit. In addition, this could open the door to collecting for
    prolonged service times if the time the doctor spends exceeds
    30 minutes more than the allotted time, and the visit notes are
    documented as such."

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