“Can I bill a level 4 E/M code if a patient presents with multiple unique, separate identifiable complaints that I am treating? For example: A patient comes in with complaints of a hammertoe and plantar fasciitis. I am treating both. Can I code a level 4 code and be justified based on the time?”
“Can I bill a level 4 E/M code if a patient presents with multiple unique, separate identifiable complaints that I am treating? For example: A patient comes in with complaints of a hammertoe and plantar fasciitis. I am treating both. Can I code a level 4 code and be justified based on the time?”
If a patient comes into the office with multiple, unique, separate, identifiable complaints such as hammertoes and plantar fasciitis and both are being treated, can a level 4 established patient E/M service, CPT 99214 be billed based upon time? The answer is yes, but… let’s take a look at the guidelines.
E/M code 99214 is defined as the following: Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter. So, total time is being used in order to bill E/M code 99214. 30-39 total minutes need to be appropriately documented. What do you need to know to do it right?
Service Based on Time – Guidelines for Selecting Level of E/M:
- 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 healthcare 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 healthcare 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 services.
Guidelines for Selecting Level of E/M Service Based on Time:
~Physician or other qualified healthcare 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
Documentation of Total Time Utilized:
How should time be documented?
For example: Document: “I spent xx minutes seeing the patient, x minutes coordinating care with the physical therapist at the physical therapy facility and x minutes documenting in the medical record.”
For a CPT 99214 based upon total time, all of the minutes that are appropriately spent performing the E/M service, 30-39 minutes, need to be specifically documented, showing exactly how all of the time was utilized. 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.
This is my opinion.
Michael G. Warshaw, DPM, CPC
Terrific NEWS!!!
THE 2025 PODIATRY CODING MANUAL IS NOW AVAILABLE in either Book or Flash-drive formats. It has been completely updated for the calendar year 2025. Many offices across the country consider this to be their “Bible” when it comes to coding, billing, and documentation. The price is still only 125.00 including shipping! To purchase, access the website drmikethecoder.com.
No credit card? No problem! Just send a check for 125.00 to the following address:
Dr. Michael G. Warshaw
2027 Bayside Avenue
Mount Dora, Florida 32757
Read Comments