Using time to determine evaluation and management code levels
THE AMERICAN MEDICAL ASSOCIATION (they own the CPT code set) in January of 2021 changed the criteria for determining the proper code level of evaluation and management (E/M) services. Currently, you would use either medical decision–making or time to establish the correct E/M code level.
Now before someone in the back gets too excited thinking we no longer need to collect histories and perform physical exams, you need to know the E/M codes include a medically appropriate history and physical examination. They are no longer used to determine the correct level of coding. Besides, the standards of care within the profession require appropriate histories and physical examinations.
Elements of coding and MDM
If you are going to use medical decision–making (MDM) to determine the correct E/M code level, you need to consider three elements:
- The number and complexity of problem(s) addressed during the encounter
- The amount and/or complexity of data to be reviewed and analyzed
- The risk of complications and/or morbidity or mortality of patient management
Determining the correct E/M code level using MDM requires detailed knowledge of what is included in each of these elements, how they are to be considered, and how they interact with your documentation. And there is room for interpretation to some degree in each of these elements. It can sometimes be confusing for a certified coder, much less for someone untrained who does not do this on a daily basis.
Elements of coding and time
In contrast, coding E/M service using time is fairly straightforward. If you take 27 minutes with the patient, you use that specific code. The trick with using time is you need to know the rules for coding with time.
The first rule concerns face–time and non-face–time. This is the time considered for coding purposes if it’s face-to-face time the physician spends with the patient or their family or caregiver, and the non-face-to-face time spent personally by the physician on the date of the encounter. Time your support staff members (CAs) spend, such as having the patient complete history forms, does not count for coding purposes.
The second rule is you only include the total time on the date of the encounter. For example, if you examine the patient in the morning and have them return in the afternoon for the report of findings, the ROF would count toward the total time. If you had the patient return the next day, the ROF would not count toward the total time.
The third rule is there are specific activities allocated toward the total time, including:
- Preparing to see the patient (e.g., 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)
Remember, these activities must be performed by the doctor to be counted. Also, there are activities listed specifically that do not count, including:
- Performing other services that are reported separately
- Teaching that is general and not limited to discussion required for the management of a specific patient
The fourth rule is to know the code levels and the times associated with them. For new patients (defined as any patient not seen within your practice in the past three years) the codes are:
- 99202: 15-29 minutes
- 99203: 30-44 minutes
- 99204: 45-59 minutes
- 99205: 60-74 minutes
For established patients, the codes are:
- 99211: No physician presence is required for this code (99211is for simple exams performed by nurses such as blood pressure, pulse, respiration, etc.)
- 99212: 10-19 minutes
- 99213: 20-29 minutes
- 99214: 30-39 minutes
- 99215: 40-54 minutes
Rules around the use of time
Now that we know the rules surrounding the use of time to determine the correct E/M code, how do we properly document the required information? Regarding this one detail, there is no guidance, so we need to use our own judgment in this matter.
My recommendation is that to use the same method used when documenting timed therapy codes. Specifically, we list the activity, the time the activity was started, the time the activity ended, and the total time for the activity. The following is an example I developed of a time coding audit form:
|Time Coding Audit|
|Activity||Start Time||Finish Time||Total Time|
|Prepared new patient packet||8:15||8:19||4 min.|
|Reviewed history, did consult and exam||10:12||10:34||22 min.|
|Reviewed X-ray and exam, developed X-ray report and plan of care (POC)||12:42||12:57||15 min.|
|Reviewed results and POC w/patient||3:16||3:30||14 min.|
|Total Time||55 min.|
You could easily make a similar form with lined paper. If you put this information in narrative format, it would look like this:
“Started preparing to see the patient at 8:15 a.m. by preparing initial patient packet and finished at 8:19 a.m. for a total of 4 minutes. Started reviewing patient’s history at 10:12 a.m. then performed consultation and examination, finishing at 10:34 a.m. for a total of 22 minutes. X-rays were ordered and patient was told to return this afternoon to review plan of care and start treatment. Reviewed X-ray and exam results and developed plan of care starting at 12:42 p.m. and finishing at 12:57 p.m. for a total of 15 minutes. Patient returned in the afternoon and reviewed exam results, X-ray results, and plan of care starting at 3:16 p.m. and finishing at 3:30 p.m. for a total of 14 minutes. Total time spent on E/M service was 55 minutes resulting in code 99204. Treatment was initiated at 3:35 p.m.”
Note: In the narrative format, I specifically listed the start time of the adjustment. This is because adjustments are coded and billed separately and because this differentiates the adjustment from the initial exam. The adjustment codes are bundled codes and contain an examination element.
The national correct coding initiative edits indicate you cannot bill an adjustment and an exam on the same date of service unless there is clear indication the exam is significantly more involved than the one bundled with the adjustment code. To indicate this is the case you would use the -25 modifier with the E/M code.
Keep your billing patterns consistent
Your level of E/M code should be consistent with the complexity of the patient’s chief complaint. If every initial visit was coded to a level 4 E/M service, it would not be long before third–party payers would start looking at you very closely.
However, if your simple cases were coded at the lower level and E/M codes and the more complex cases were coded at the higher level, you would fall within the expected billing pattern.
RON SHORT, DC, MCS-P, CPC, CPCO, is a 1985 graduate of Palmer College of Chiropractic who presents seminars and webinars across the country on Medicare, compliance, coding and billing, and documentation. He has written five books and several articles on Medicare, billing, coding, compliance and documentation. He is available to speak at your group or association meeting or to assist you with reviews, audits, appeals or the development of a compliance program for your office. He can be contacted at email@example.com or at 217–653-5921.