Within the guidelines of the CPT code book, CPT has stated; “When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services.
What this means to our physicians and providers, is that time alone can be used to select a level of care, and bill for our services regardless of the clinical documentation of history, exam and medical decision making. If these physicians and providers utilize the option of documentation of “Time” in the clinical notes, they still have to document the care given, but it can be noted that they spent “XX amount of time” at the bedside and/or on the unit in care of the patient and of that 50% of this time was spent in counseling, and coordination of care of “XXX diagnosis, testing, etc.”
Time-based clinical documentation does need to be very specific, The face-to-face time spent in an outpatient or office type setting includes not only the time the provider spent counseling and coordination of the patients care but has to be rendered face to face with the patient. Any pre or post time spent (when patient and provider are not face-to-face) cannot be included in the time component described in the CPT E&M codes.
From a revenue and denial standpoint, it is frustrating to have an auditor or insurance carrier review the clinical chart and down code the admission from a 99222/223 to a low-level admission 99221 due to skimpy history, exam, or medical decision notations.
- The CPT code 99221(level 1 admit) requires a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making of straightforward or low complexity;
- The CPT code 99222 (level II admit) requires a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity,
- The CPT code 99223 (level III admit) requires a comprehensive history; a comprehensive examination; and medical decision making of high complexity.
Also within meeting these criteria, all three key components are to be met. The only difference between a 99222 and a 99223 code is the medical decision making of moderate complexity vs. high complexity.
Not all CPT E&M services have a time-based component that can be utilized to represent the care provided. Within the CPT codes outlined for usage in an Emergency Department, “Time” is not a descriptive component, and all three key components for each CPT code 99281 – 99285 must be denoted within the emergency department patient visit.
If the provider is providing care for a patient that is on a hospital unit or floor, the intraservice time for these codes is noted or defined as “unit/floor time” which includes the time present on the patient’s hospital unit and at the patient’s bedside providing services for that patient. In this setting, this includes time to establish and review the patient’s chart, examine the patient, write clinical notes, documentation, orders and to communicate with other providers and the patient’s family. In this hospital setting the pre and post time including time spent off that patient’s floor are not to be included in the time component noted in the CPT code descriptors.
Appropriate time statement examples:
- Time in was 14:00, time out at 15:06, I spent 40 minutes of the 66 minutes in the encounter counseling the patient on their diagnosis of “xxxxx” and the remainder of the time was spent obtaining the HPI and examination of the patient.
- I spent greater than 50% of my 30-minute visit with the patient discussing the options of surgery versus watchful waiting regarding their diagnosis of “xxxxxx”
Inappropriate Time Statement Examples:
- I had a lengthy discussion with the patient.
- I spent 20 minutes in supportive counseling.
- I spent 15 minutes talking about the treatment options.
- I spent 30 minutes with the patient
Medical Billers and Coders (MBC) have a team of certified coders who has diverse experience of E/M coding. To know about our coding services you can call us at 888-357-3226 or email us at firstname.lastname@example.org