Appropriate E/M Code to Bill Based Upon Time

Help! Can you please explain what is needed to determine the most appropriate E/M code to bill in the office based upon time?

Summary of the Changes

•      • Time is defined as total time spent, including non-face-to-face work done on that day and no longer requires time to be dominated by counseling.
•      • It includes time regardless of the location of the physician or other qualified health care professional (eg, whether on or off the inpatient unit or in or out of the outpatient office).
•      • It does not include any time spent in the performance of other separately reported service(s).

Guidelines For Selecting Level of E/M Service Based on Time

•      • For coding purposes, time for these services is the total time on the date of the encounter.
•      • It includes both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff)
•      • It includes time regardless of the location of the physician or other qualified health care professional (eg, whether on or off the inpatient unit or in or out of the outpatient office). It does not include any time spent in the performance of other separately reported service(s).
•      • If a procedure is performed and billed using a separate CPT code, you should not include that in the time for the E/M code.

The Total Time that is used to calculate the level of E/M service needs to be specifically broken down into the component parts:

•      • Physician or other qualified health care professional time includes the following activities, when performed:
•      • preparing to see the patient (eg, review of tests)
•      • obtaining and/or reviewing separately obtained history
•      • performing a medically appropriate examination and/or evaluation
•      • counseling and educating the patient/family/caregiver.
•      • ordering medications, tests, or procedures
•      • referring and communicating with other health care professionals (when not separately reported)
•      • documenting clinical information in the electronic or other health record
•      • independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.
•      • care coordination (not separately reported)

Do not count time spent on the following:

       1. The performance of other services that are reported separately

       2. Travel

The Physician or other QHP must document total time utilized (e.g., “I spent a total of 15 minutes reviewing patient’s labwork, discussing referral option to specialist, setting up X-rays and discussing diagnoses with patient and spouse).

•      • In this example, a new patient office visit could be coded at 99202 or an established patient office visit as 99212.

Can the provider sign the note the next day?

•      • The provider can sign the note whenever he or she wants to, but if using time, only count time on the date of service. Therefore, you cannot add the time spent documenting the encounter unless it was documented on the actual date of service.

Example: Here's how the time for each activity could break down, and how the physician or QHP could track it.

Activity: Time (minutes)

Pre-visit planning, chart review, and face-to-face encounter: 18 (tracked by EHR)

Review of urgent care records (received after visit, same day), with brief summary noted in EHR: 6 (tracked by EHR)

Discussion of medications with pharmacy technician: 11 (recorded by phone)

Phone call with family member (POA): 13 (recorded by phone)

Coordination with office staff for med adjustments and bubble packing: 5 (estimated)

Final documentation of visit: 4 (tracked by EHR)

Total time: 52 (code 99215)

This is my opinion.

Michael G. Warshaw

DPM, CPC

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