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Thread: Time based coding - need refresher please

  1. #1

    Default Time based coding - need refresher please

    AAPC: Back to School

    I have physicians that will document an E/M level say for an office follow up, after auditing it will come out to a 99215 based on E/M elements. Ok of the same note they will document something like this.. " I have spent 30 minutes total time with the patient discussing treatment options and a plan of treatment.

    Ok, a 99215 equals to 40 minutes.. which takes precedence? The E/M level of the note 99215 or the fact that they documented the total time with the patient of 30 minutes? I have been told by the physician (s) that they have indeed spent 30 minutes. So in this scenario are they short changing themselves? I say they are.. I am sorry I was not more specific in my previous entry.

    Anyone else?

    Last edited by Love Coding!; 01-12-2012 at 11:06 AM. Reason: Added more detail to my post

  2. #2
    Join Date
    Apr 2007
    Carmel, New York

    Default Use the elements

    If documenation of the elements supports 99215, use that. The 40 minutes for time spent is what amount of time is "typically" spent with the patient.


    2016 Secretary
    Ellenville, NY Local Chapter

  3. #3


    Quote Originally Posted by MnTwins29 View Post
    If documenation of the elements supports 99215, use that. The 40 minutes for time spent is what amount of time is "typically" spent with the patient.
    Thank you Lance, don't you think they would be short changing themselves if their note reflected a higher level of service than what they documented for "total time". I want to break them out of the habit of doing this. I feel this would be a great educational opportunity on time based coding.


  4. #4
    Join Date
    Apr 2007
    Concord, NC or Rochester, NY


    Time based can only be used when a visit turns to consulting. If they are documenting the key elements and not performing counselling, then the key element is the only way to go. The average time in CPT is only that - the average time. It is this time that is utilized when looking at time based coding but don't let anyone tell you to use the time when there is no type of counselling, etc.

  5. #5
    Join Date
    Apr 2007
    Milwaukee WI

    Default Experienced clinician

    An experienced clinician can perform and document a 99215 in FAR less time than 40 minutes.

    Don't worry about it. You may code to whichever standard is met ... You say that key elements = 99215, so you are fine coding 99215.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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