2021 E/M Guidelines: Understanding Total Visit Time

Stephani: Welcome, everybody, to our Listen-Up Series on 2021 E/M Guidelines. Today, we're going to be talking about total visit time. My name is Stephani Scott, and I will be your host today. I have worked in the healthcare industry for over 25 years. During that time, I've had the pleasure of working in a variety of different settings, including acute hospital, long-term care, large multi-specialty physician groups, and I've worked for a major EMR vendor doing design and development work. For several years, I was a part-owner of a consulting company in which we provided services for physician practice management, including coding, billing, and revenue cycle. Currently, I am the vice-president for AAPC's audit services. My guest today is Elizabeth Hylton. Elizabeth, will you introduce yourself?

Elizabeth: Absolutely. I am a regional director with AAPC Audit Services Group. I have about 17 years’ experience in the healthcare administration setting. I hold the credentials of CPC and CEMC, and I've had the privilege of working pretty much every line of service in the admin field of healthcare. I started off as a front desk person in a family practice clinic, and gradually worked my way through the revenue cycle, from denials all the way to claims processing, and then auditing in a retrospective manner. So, I've pretty much done it all. If you can do it administratively in healthcare, I've done it.

Stephani: Well, that's great. You're perfect one to join me today for our webinar. Okay. First, what we thought we would do is talk about the new time-based definition and how the calculations work. Then I actually pulled some real-life office visit scenarios. Obviously, we've redacted them and tweaked them just a little bit, but these are scenarios that we've come across over the last several months. And then finally, Elizabeth, I wanted to go over some common questions that we keep getting from different organizations.

Elizabeth: Sounds great.

Stephani: So, okay, perfect. With that, let's go ahead and get started. So we now have these two different time standards and calculations. Elizabeth, can you tell us what are the difference between these two?

Elizabeth: Absolutely. So, under the system we're used to, '95/'97 guidelines, we had to put a statement in there that showed we spent greater than 50% of a total visit face-to-face with our patient counseling and coordinating care. Now, this is still going to be the case with our other E/M categories, just not the office and outpatient setting. For that under our new 2021 calculation, it is going to be based just on total visit time on the day of the patient encounter. So much, much simpler in the office and outpatient world.

Stephani: Okay. Thank you. So Elizabeth, tell us exactly how this new total visit time is defined and what activities can be counted towards that total time.

Elizabeth: That's a great question. So total time is being defined as what is spent on the day of the patient encounter. It is going to include both face-to-face and non-face-to-face activities. And we have it broken down on the slide here that we're referencing. We have things that we can include and things we can't include. So things we can include, prep on the same day, obtaining and reviewing history from our patient's records, the exam that we perform with them, any counseling and ordering of tests, medications, and procedures, okay? So things that are typically associated with the evaluation and management service that our providers historically have not been able to count like their prep work.

Charting is also included on this, care coordination. All of those services that previously we couldn't really get credit for because they didn't take place face-to-face with the patient, now we can include. And no longer do we need to use the statement of greater than 50% of time was spent in counseling. It's just the total time that you spend taking care of your patient on that day.

Stephani: Okay. So what types of activities are not included?

Elizabeth: So some of the things that we would not include, we have to bear in mind that this is provider time only. It is not going to count staff time. It is not going to count the separately reported tests or procedures that you perform on the day. So if there's a CPT code associated with something that you're doing outside of the evaluation and management service, the time that you spend performing those identified CPT codes is not included. Slow charting is also not something that you would include.

I had a practice who was getting ready to go to a new EMR system in February. And they're very concerned about having two learning curves to come up to, but we had to make sure we were very clear there's a reasonable expectation surrounding how long it takes to chart, and that's what we count. Not necessarily coming up to a learning curve in an EMR. And then, of course, any elements that are performed on a different date. So depending on your provider's flow and the way they like to practice medicine, if they are doing prep work the day before they see a patient or they're doing review the day after they see a patient, those elements will not count. It has to be elements that are performed on the same calendar date as the patient encounter.

Stephani: Okay. Great. That's some good insight. Okay. On this slide deck, we've broken out the different time ranges. So Elizabeth, kind of walk us through the ranges for new patient and established patient.

Elizabeth: Okay. This is the first time when I reviewing these guidelines initially that I went, "Whoa, that's different," because we're very used to seeing a static point in time assigned to these codes. You know, it's been very easy for me previously to just rattle off, "Oh yeah, you need 15 minutes for a 99213," or, "You need 25 minutes for a 99214." That's not the case anymore. Now it's defined by a range of time and your static point will fall into this range.

So as you can see, there's kind of a pattern with this. New patients are gonna start at 15 minutes and they're gonna go up in 15-minute increments. So once you hit 30 minutes, you're at a 99203, once you hit 45, you're at a 99204, 60 for 99205, and so on versus under the established patient rules, we have to start with 10 minutes for a 99212, and then we billed in 10-minute increments. You start with a 99213 once you hit 20 minutes, 30 minutes for a 99214, and so on.

So we've been encouraging our providers, you know, you have to understand you're now being defined by a range of time, but please do not document a range of times. Tell us the static amount of time that you spent with your patient on this day, and then a coder will assign the appropriate E/M based on what you're telling us in documentation.

Stephani: Okay. Great. So there has been some confusion on whether or not CMS has adopted these time ranges. Can you help us with that?

Elizabeth: From my understanding, they have adopted this. This is in the CPT books for 2021. The only place where CMS kind of gets a little different from AMA is going to be with calculation of prolonged services. Those rules are a little bit different.

Stephani: Okay. Thanks for clarifying. Let's go ahead and talk about the prolonged services. So Elizabeth, help us define the AMA's guideline here.

Elizabeth: All right. So AMA has released a new code for 2021 CPT code set, and this is 99417. This will define 15 minutes of prolonged office or other outpatient evaluation and management services beyond the total time of the primary procedure which has been selected using total time. So we can only use these with 99205 and 99215 only, okay? These are not going to apply to the remainder of the office and outpatient code set. We have to remember that for our other categories, we're still going to continue to use the prolonged services codes we're used to seeing represented by the range of 99354 to 99359, 99415 and 99416.

So, CPT has given us some really good examples of how to calculate this when we're reporting 99417, an initial time unit of 15 minutes should be added once the minimum time in the primary E/M code has been surpassed by that 15 minutes. So, for example, we're not gonna report 99417 until at least 15 minutes of time beyond 60 minutes i.e., 75 minutes has been accumulated. The same is true for 99215. We have to get to 15 minutes past 40 minutes or 55 minutes before we can bill prolonged services.

Stephani: Okay. So on this slide, we've got those time ranges for prolonged new patient and prolonged established patient. Now, does the times stop, the prolonged time maximum stop at the four units that I have listed on the slide, or does that continue on?

Elizabeth: It can continue based on how much time is being spent with the patient, and it does not have to be contiguous, it can be incremental. So let's say you spend 40 minutes this first hour, and then you come back to the patient later in the day and you're spending more time. All of it is cumulative. Again, based on the date of service of the patient encounter. So if you're spending units past four, then we just have to remember it's in 15-minute blocks. So we have to balance how much time is being spent in what we're describing in our notes versus math here. So we have to make sure that those two things are lining up, but you can bill past four units.

Stephani: Okay. All right. Thank you. So now tell us what the difference is with the CMS prolonged services.

Elizabeth: All right. So Medicare has decided to assign a status indicator of invalid to CPT 99417. Meaning if you were to bill that code to CMS, they would not return payment for it. Instead, they have adopted their own HCPCS code for this, which is G2212. The description is similar. It's the prolonged office or other outpatient evaluation and management services beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service, each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient context. 

And the thing we have to remember here is this code kicks in for time beyond the maximum required time of the primary procedure. Once again, it can only be used with 99205 and 99215. You will not be able to report this code on the same date of service as our other prolonged services codes, 99354 to 99359, 999415, and 99416. And we have to remember we cannot report G2212 for any time unit less than 15 minutes. There is not a midpoint to this code. We have to satisfy 15 full minutes before we can bill it.

Stephani: Okay. So on this slide, we've broken out those specific time ranges. So, for example, if I'm looking at a new patient record and my total time were 90 minutes for CMS, could I also bill 99205 and the G2212 with one unit?

Elizabeth: So based on this, if we have a new patient for 99205, we would not be able to bill the G2212 because we've not surpassed that 15-minute mark. Well, wait a minute, hold on. Let me look at this. It's early in the morning, my brain is not massing correctly. So G2212 does describe that range of time. If we look at 99205, it does appear based on this table, we will be able to bill the G2212 on 90 minutes for a new patient. What we have to remember is that the full 15 minutes are past the max time of the code.

So, whereas we are looking at less time under the AMA guidelines, Medicare requires more. My rule of thumb talking to these providers is that you have to hit at least 15 minutes past the maximum amount of time for this code before you even consider upending G2212. And that's true for both new and established categories.

Stephani: Okay. So the 89 minutes is that 15-minute mark for new, and the 69 is that 15-minute mark for 50. Okay. Got it.

Elizabeth: Correct.

Stephani: Thank you. All right. So CMS released this new HCPCS code G2211, and we have just been getting a ton of questions about this new code and how practices can get paid for it. So, Elizabeth, can you help us better understand this new code?

Elizabeth: Sure, absolutely. This is something that CMS released to describe visit complexity that was inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed healthcare services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. The spirit of the code was great. And when I read this, I instantly thought, wow, this is like the spirit of transitional care management without actually having to have the inpatient admission associated with it and all the rules that go with that code set. This is wonderful. It's gonna describe additional time, intensity, and practice expense for services that are building that longstanding relationship and addressing the majority of patient healthcare needs over time.

This is exactly what we're seeing with some of our older population. They have multiple chronic conditions that are being evaluated and the physician should be compensated for the care relating to those conditions. But then literally at the 11th hour, 2:00 a.m. on December 1st, Medicare came back and said, "We're not going to price this code. It is not going to be effective for payment until January 1st, 2024." So we have to wait on this for about three more years, and then we will be able to account for increased visit complexity.

Stephani: Okay. Thank you. A little disappointing we're not able to use it yet, but it's good that it's coming in the future. Something to look forward to, for sure.

Elizabeth: Absolutely.

Stephani: Okay. So let's go over some scenario. So Elizabeth, I'm just gonna pass this directly over to you.

Elizabeth: Okay. Fantastic. So let's talk about a patient. Their chief complaint is going to be a goopy eye. Their mom reports the patient woke up with left eye matted shut. The eye is itchy and watery. The mother denied the patient having any fever, ear pain, rhinorrhea, or rash. Patient's not on any medication. The provider documents an exam of vision, right 10 out of 10, left 10 out of 13, eye is injected, pupils equal round reactive to light and accommodation, extraocular movement's intact, no periorbital edema, or erythema, or tenderness. And then they give an assessment of conjunctivitis. They give a prescription for Polytrim drops, three drops to the affected eye five times a day for seven days. And we instructed the mom to call if the patient develops a fever. Provider also denotes a total visit time of 12 minutes. So based on that documentation of time, we are going to have a 99212 as our level.

Stephani: Okay. Perfect. Now I noticed on that time, all it says is just the minutes, the total visit time 12 minutes. Is that gonna suffice the documentation requirement? Don't we have to put more to that?

Elizabeth: It's minimally acceptable. Now me as an auditor, my brain does a thing where I would probably want to see more, but the provider is saying that the total visit time on the date of service is 12 minutes. So it is sufficient. If it were me, I would probably educate them to flesh that out just a little bit. Total visit time spent in E/M service exclusively 12 minutes, and you're good to go.

Stephani: Okay. So this next scenario kind of addresses that. Can you help us walk through it?

Elizabeth: Absolutely. So we have a statement that the provider spent greater than 45 minutes with the patient and greater than 50% of that counseling on diagnosis treatments, previous test results, histories, and updating EMR as described above. Now that is absolutely textbook from a 1995/1997 documentation standpoint. For 2021, we're gonna switch that up a little bit. And the provider will now document, "A total of 60 minutes was spent today reviewing the patient's diagnostic tests, assessing and examining the patient and documenting. None of this time was spent performing separately billable procedures or ancillary services.

So what the provider does well with this 2021 is he gives us the exact total time that was spent with the patient. He avoided language like at a minimum or approximately. It was 60 minutes that was spent today. So he's letting us know this was all spent on the day of the patient encounter. The documentation of what was performed ideally is going to be patient-specific. Now I underlined this on my notes, reviewing patient's diagnostic tests, assessing and examining the patient and documenting, that is not a requirement of 2021.

However, many organizations that I've provided this training to, they have adopted it from a best practice standpoint to support individuality from one patient to the next. I would caution our providers to be careful of using templates that look identical from one patient to the next. Copy-paste is still going to be a concern in 2021. And I suspect given time is one of only two components used for selecting levels in the office and outpatient setting, time-based billing is going to come under even greater scrutiny. So we have to be careful that what we're saying we're doing from a time perspective is backed up with what's actually being done in documentation.

Stephani: That's some good advice, Elizabeth. Thank you. Okay. So we have a third scenario with a prolonged time. Can you walk us through this one?

Elizabeth: Sure. So we have an established patient here, so we're already going to be looking at our...if we're planning on doing a prolonged service, it's gotta be at least a 99215. The patient presents with fluid retention and shortness of breath. The assessment and plan diagnose this patient with congestive heart failure. The provider goes on to say that they spent 62 minutes obtaining records from primary care, evaluating their patient, and discussing treatment options to include fluid restriction, a low-salt diet, and compression hose.

If the patient continues to retain fluid, we'll consider low-dose Lasix. So under the AMA guidelines, this is enough to substantiate both the 99215 and one unit of 99417. Given the fact this was congestive heart failure, I instantly think this is probably a Medicare-aged patient, and under CMS rule, this will only substantiate a 99215. It will not meet the threshold in order to bill the additional 99417, or in the Medicare patient's case, the G2212.

Stephani: All right. Thank you, Elizabeth. Yep. So let's move on to some common questions that we keep getting. So I'll go ahead and read the questions. Are there guidelines on which calculation to use, MDM or time?

Elizabeth: The guidelines that we have specifies that an E/M service should be selected based on either MDM or time? So whichever one is beneficial to the provider, if the provider substantiate their level on time, MDM does not also have to be documented and vice versa. If the time and MDM are both documented and they can split, so let's say one component supports a lower level than the other, we'll use whichever component is beneficial to the provider.

Stephani: Okay. So the next question is when time is documented, does time trump MDM?

Elizabeth: This is a great question. Not always is the answer. For example, if by time a provider supports a 99213, let's say they spent 20 minutes with their patient, but the medical decision-making supports a level four because they have management of two stable chronic conditions with moderate risk to the patient, and the provider bills that level four, the level is supported by their medical decision-making as outlined in documentation. There was initially some discussion amongst providers that they just bill based on time since it was easier. And if that's all they have to put in their note, cool, that's what we're gonna do.

And we had to remind our providers you have to understand, in some cases, they'd be selling themselves short because of how time had been restructured now with that range instead of a static point, but to bill based solely on time would actually hurt their bottom line. So time does not always trump MDM. And I don't feel like if a provider substantiates a greater level of MDM, it would be fair to rely on the time. Their cognitive work is right there on the paper for us to see, and it may exceed the amount of time that was spent.

Stephani: Thank you. That's some great insight. So our last question is if MDM supports a 99215, however, the total visit time supports a 99214, should 99214 be reported to avoid reporting a level five as a target? So we all know about the E/M bell curve and the watchful eyes of the payers on those higher levels. So in this case, what should we do?

Elizabeth: Well, I tend to take those bell curves with a grain of salt. They are excellent tools to establish a baseline and a benchmark and help our providers understand what their colleagues nationwide are doing. However, at some point, we have to stop thinking about those higher levels as a target that we don't want on our backs. If a provider is supporting their MDM complexity, we have to allow credit for the cognitive work that's associated with the complexity and risk. Usually, when I'm auditing, I'm looking at the medical decision-making first because that's really the clinical determination that the provider is making. And then I'll use time as a fallback if I need it.

I will very rarely look at time and pull a provider's level down, especially if he's given me a beautiful description of a high MDM. To me, that's an unfair penalty and way too stringent of a stance. So if they support their MDM but their time supports a lower level, I would go with MDM because once again, that's measurement of the provider's cognitive effort on paper and they should be giving credit for the work that they're performing.

Stephani: That's excellent advice. Well, this concludes our Listen-Up Series on the 2021 E/M Guidelines, understanding total times for those guidelines. Elizabeth, thank you so very much for being my guest. And thank you, everyone, for joining us. Have a great day.