Coding Corner: Time as the controlling factor in E&M coding

September 01, 2014
Area(s) of Interest: Payor Issues and Reimbursement Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, managing editor for AAPC, a training and credentialing association for the business side of health care.  

CPT® guidelines allow you to consider time as “the key or controlling factor to qualify for a particular level of [evaluation and management (E&M)] services” when counseling and coordination of care dominate (comprise more than half) the physician/patient encounter. Coding based on time may allow you to select a higher-level E&M service than would otherwise be appropriate, based on the elements of history, exam and medical decision-making. 

Counseling and coordination of care entail a discussion with a patient and/or the patient’s caregivers concerning one or more of the following:

  • Diagnostic results, impression and/or recommended diagnostic studies

  • Prognosis

  • Risk and benefits of management (treatment) options

  • Instructions for management (treatment) and/or follow up

  • Importance of compliance with chosen management (treatment) options

  • Risk factor reduction

  • Patient and family education

You should document all pertinent information discussed during the session in the medical record. For example, “30 minutes of counseling” isn’t sufficient. Instead, the provider should summarize the discussion that comprises the counseling or coordination of care. Best practice is to document the beginning and ending time of the counseling and/or coordination of care, and the beginning and ending time for the overall face-to-face visit.

When reporting E&M services by time (rather than the key components of history, exam and medical decision-making), you should use CPT® “reference times” to determine an appropriate E&M service level. The reference time is stated in the final sentence of the CPT® E&M code descriptor (e.g., “Physicians typically spend 30 minutes face-to-face with the patient and/or family”). Reference time for established outpatient codes are:

  • 99211 = 5 minutes

  • 99212 = 10 minutes

  • 99213 = 15 minutes

  • 99214 = 25 minutes

  • 99215 = 40 minutes

CPT® states, “When codes are ranked in sequential typical times and the actual time is between to typical times, the code with the typical time closest to the actual time is used.” For example, when reporting a time-based, established outpatient E&M lasting 19 minutes, you would report 99213.

Consider the following sample note:

Family discussion on 5/10/2014 with Jane Doe (daughter) and Joe Doe (son) regarding their mother Mary Doe, MRN # 12345, DOB 2/2/45. Mary is a current patient of mine who was recently diagnosed with cancer of the left breast that is very aggressive. I discussed prognosis and treatment options for Mary’s aggressive breast cancer, including surgery, recovery time and chemotherapy and its side effects. I gave them literature from the American Cancer Society, and the name of local support groups that they could contact. I spent a total of 42 minutes with Jane and Joe. Both parties verbalized understanding. I answered all their questions, and they are in agreement with my plan, as outlined above.

In this case, proper code selection is 99215 (with a reference time of 40 minutes).

A final consideration: Not all E&M service codes include reference times. For example, per CPT®, “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 reference time. Because these services do not include reference times, they should not be reported with time as the controlling element. 


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