E/M and Time thresholds
Billing E/M with Time as the Main Factor can effect Reimbursement
By Terry Fletcher, BS, CPC, CPC-Cardio, CPC-E/M, CMSCS, CMC, CCS-P, CCS
Physicians, Cardiologists and Internal Medicine Physicians in particular, spend a lot of time with their patients reviewing test results and discussing treatment options, and many are missing reimbursement opportunities by not taking time into account when billing for E/M services.
If they are not well informed about how time-based E/M coding works, cardiologists may code and bill visits using 99212 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: a problem focused history, a problem focused examination, or straightforward decision making), when they really have performed a 99213 ( ; expanded problem focused history, expanded problem focused examination, or medical decision making of low complexity) or 99214 ( ; detailed history, detailed examination; medical decision making of moderate complexity).
Their notes may be in perfect order, including documentation of the time spent with the patient, but they continue to base E/M codes on history, examination and medical decision-making, even when the cardiologist performs only a minor examination but spends considerable time with the patient.
According to CPT, physicians may bill for E/M on the basis of time. The last part of the E/M section in the CPT Manual states:
When counseling and/or coordination of care dominates (more than 50%), the physician/patient and/or family encounter [face to face time in the office or other outpatient setting or floor/unit time n the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. This includes time spent with parties who have assumed responsibility for the care of the patient or decision-making, whether or not they are family members (e.g., foster parents, person acting in locum parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record.
(p. 9, CPT 2004 Manual)
In other words, if the cardiologist spends more than half the time of the visit going over test results and/or counseling or coordinating the care of the patient, the categories that normally otherwise determine levels of E/M services -- history, examination and medical decision-making -- are not taken into account, though of course they are still performed and should be documented. The time must be spent counseling, coordinating the patients care, or both.
There are, however, strict documentation guidelines when billing E/M based on time to deter abuse.
The key points to remember are:
- The time spent counseling or coordinating care must be more than 50% of the total time spent with the patient.
- Time must be face-to-face with the patient (or whoever has assumed care of the patient, whether family or not).
- Time counseling must be documented.
- The entire time of the visit is taken into account, not just time spent counseling or coordinating care.
For example, a cardiologist sees a long-term patient with coronary myopathy that is progressively getting worse to discuss treatment options. The cardiologist indicates that a heart transplant may need to be performed. The cardiologist then would arrange to make the transplant available and refer the patient to a cardiac surgeon. The patient, however, has lots of questions and concerns and the cardiologist wants to discuss the issues with the patient and his wife. The total time of the visit is 90 minutes. About 60 minutes of the time was spent counseling the patient and his wife.
In this situation, the cardiologist should bill 99215 (office or other outpatient visit, for the evaluation and management of an established patient, which requires at least two of these three key components: comprehensive history, comprehensive examination; medical decision making of high complexity), using the first 40 minutes spent as the factor that determines the level of E/M chosen. The remaining 50 minutes also may be reported by using 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]) should be included for reimbursement of the remaining 50 minutes.
Note: Prolonged services codes are time-based. This means they can only be used in conjunction with other E/M services that include a time component, such as office visits, inpatient visits and consults. They cannot be used on their own or with E/M codes that do not include a time component, such as emergency department services (99281-99285). Many carriers also require that start and stop times be documented for prolonged services, much the same as with critical care codes.
The cardiologist also may spend a lot of time coordinating a patients care during a visit. For example, a cardiologist sees a long-term cardiac patient who has no family to help care for him. During the visit, doctor and patient determine the patient would be better off close to his family. The cardiologist tries to place the patient in another city by phone. The patient is present the entire time the physician is on the phone (30 minutes). The total visit was 40 minutes.
This visit, too, should be billed 99215, as the 40 minutes spent with the patient, with coordination of care occurring for more than half the time, qualifies for a 99215, because in both situations, the cardiologist must indicate the time and a summary of what transpired during that period of time, such as spent 35 minutes on phone with social worker trying to arrange adequate placement for patient with severe cardiac disease, or trying to contact physician who would be willing to assume care for the patient, or spent 90 minutes with patient and wife discussing treatment options. They were concerned about risks and benefits of each option, they will think about it and call back in a week. The patient was advised to continue on same meds in the meantime.
It is also of note that only time spent counseling or coordinating care face-to-face with the patient is counted toward the established office visit. Examination of test results away from the patient cannot be included. Face to face time means just that. It doesnt mean time spent on the phone with the drugstore or the home health company once the patient has left the office. And the patient actually has to be in the office, not just waiting in the cardiologists waiting room.
The only exception to the face-to-face requirement are inpatient codes. When cardiologists see inpatients, they may spend a lot of time not only counseling patients but also coordinating care with other caregivers, such as nurses, social workers and nursing homes. For inpatients, you are allowed to use time spent on the unit and with nursing staff as part of the time threshold for inpatient visits.
For example, the cardiologist may discuss a patients DNR (do not resuscitate) status with the patients wife and children (counseling) or may talk to the patient about his treatment options by the patients bedside or coordinate the patients care with a social worker on the hospital floor, all of which qualifies for time-based E/M coding.
Note: The level of some E/M codes cannot be determined on the basis of time. When coding for ED services or confirmatory consults, for example, the appropriate level has to be calculated using history, exam and decision making only.
Please also note that this is not a discussion to encourage only using the time thresholds for help in choosing a level of service. This article is to reflect that time can be an appropriate factor when all the guidelines for counseling and coordination of care are met and well documented. As with any e/m services, documetation will be your key. If it is not documented, then you cannot support your position on using time as your thresholds for e/m services. But, if the documentation is accurate and your are ever audited, you will be able to justify the codes that were billed without penalty or refunds to the clinic.
Terry A. Fletcher, BS, CPC, CPC-Cardio, CPC-E/M, CMSCS, CMC, CCS-P, CCS
Healthcare Coding and Management Consultant
AAPC Local Chapters Board of Directors, Executive Chair 2007-2009 (AAPCCA)
27881 LaPaz Road, G156
Laguna Beach, CA 92677