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E/M Time-Based Coding

The physician or other qualified healthcare professional are using CPT codes from the range 99202-99499 which is called Evaluation and management (E/M) codes to represent services offered by physicians.

These codes are applicable while evaluating and managing patient health. These (E/M) codes have been around for many years still reporting timed-based services is confusing.

So let’s understand the evolution of coding practices in brief:

  • How coding practices evolved?

Before 1992, time is the only an implied factor in the CPT codebook, and E/M codes had only descriptors which lead to creating confusion for physicians as well as payers.

For example- Physicians are not sure about determining what E/M level to report and payers could not assess the clinical documentation and reported E/M levels objectively.

This problem is getting attention and requires more clarity on time hence the American Medical Association (AMA) started to include time as a factor. AMA help in the selection of the most appropriate E/M level for various services such as office and other outpatient services, inpatient services, and consultations.

Today, various terms that we use for time-based E/M categories, for example, total time, total visit time, face-to-face and non-face-to-face time, greater than 50 percent, CPT midpoint rule, and rounding are the result of the evolution of codes after 1992.

However, reporting timed-based services can still be confusing. Here we are trying to simplify time-based rules.

  • Definition of Time for Office/Outpatient E/M

The definitions and roles of time differ depending on the category for E/M coding hence coders and providers must be aware of these differences to ensure proper documentation and coding.

Rules for various types of E/M codes are explained in the time section of the E/M guidelines, including office and outpatient E/M codes 99202-99205 and 99212-99215.

Outpatient E/M coding

Visit level

New patient code New patient time(Min) Established patient code Established patient time(Min)
Level 2 99202 15-29 99212 10-19
Level 3 99203 30-44 99213 20-29
Level 4 99204 45-59 99214 30-39
Level 5 99205 60-74 99215 40-54

Total time combines the time provider spends on the face-to-face and non-face-to-face encounter on the encounter date. There is a summation of overall time spent over the day with the day starting at 12:01 am and ending at midnight.

Various tasks like reviewing tests before the patient are present or coordinating care after the patient leaves, the time required for the visit may be included while calculating the total time.

Moreover, there is a revision in total visit time for 2021 to include both face-to-face and non-face-to-face time personally spent by the physician as well as other healthcare professionals on the day of the encounter.

A most important point to remember here is total time does not include the time spent on activities normally performed by clinical staff.

Here is the list of activities counted toward a physician’s total time:

  • Preparing to see the patient (e.g., review of tests)
  • Performing a medically appropriate examination and/or evaluation
  • Ordering medications, tests, or procedures
  • Obtaining and/or reviewing the separately obtained history
  • Documenting clinical information in the health record
  • Referring and communicating with other healthcare professionals (when not separately reported)
  • Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
  • Counseling and educating the patient/family/caregiver
  • Care coordination (not separately reported)

However, with the 2021 E/M code and guideline changes, you may no longer apply the “greater than 50 percent” counseling and coordination care rule to the office and other outpatient E/M services.

  • Reporting of E/M service that is not based on time

Not every E/M service allows reporting the level based on time hence it is needed to look at CPT code descriptors and other documentation requirements.

E/M services which are based either on examination, key components history and medical decision making or time using the greater than 50 percent counseling and/or coordination of care guideline include:

  • Inpatient and Subsequent Services
  • Observation Services
  • Nursing Facility Services
  • Inpatient Consultation
  • Outpatient Consultation
  • Domiciliary/Custodial Care
  • Home Services

After knowing the role of the time component in E/M services, coders must know how to eliminate the confusion surrounding time-based coding.

Hence here some tips to help coders:

  • Must make a habit of reviewing the code descriptors for the key terms that differentiate the specific rules
  • Understand how and when to apply the rules
  • Work with your providers to ensure their documentation can stand up to the scrutiny of any payer.

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