Coding Your Evaluation & Management Services Based on Time
There are instances when your patient encounters are not driven by the key components of history, examination and medical decision making. In some cases, it is more relevant to select the level of service based on the time spent with the patient.
The CPT® book states, “When counseling and/or coordination of care dominates (more than 50 percent) the encounter with the patient…then time shall be considered the key or controlling factor to qualify for a particular level of E&M services”. Your medical record should include the total time spent with the patient and the amount or percentage of the total time that was spent in counseling.
The documentation should be descriptive about the nature of the discussion or education provided. Some common scenarios for billing based on time are counseling regarding: prognosis and treatment planning, risks and benefits of management of the condition, importance of compliance with the plan of care, or education and instructions for management of the disease.
Here are some examples of documentation that would satisfy the requirements:
- “We spent more than 50% of our 45 minute visit discussing the prognosis, plan, additional treatment, and the overall outlook for Stage IV non-small cell lung cancer.”
- “I spent 25 minutes with the patient, 20 of which was spent reviewing recommended dietary changes and educating her on carb counting and sliding scale insulin.”
In the office setting, this would be face-to-face time with the patient. Time spent reviewing records prior to the patient’s visit or speaking with a referring physician to accept a consultation do not count toward the face-to-face time in the office setting (these should be documented, however, as they are a factor in the medical decision making component of the E&M when not billing based on time). In the hospital setting, both face-to-face time and unit time can be used to calculate the total time spent. Unit time includes, in addition to the bedside time: reviewing the chart, placing orders for diagnostic studies or ancillary evaluations, and communicating with other medical professionals. Also specific to in-patient services, discussions with family may count toward the time if it is well documented that the patient is unable to participate in making decisions about his/her care and therefore the family meeting is necessary to decide on treatment plans.
So, if counseling, educating or coordinating care is the overriding reason for the encounter, document the total time spent, the amount spent in discussion, and the nature and content of your conversation. When supported in the medical record, the time will replace the history, exam and medical decision making as the determining factor for the selection of the level of service.
The times associated with various categories of E&M codes appear below.
Sources: Current Procedural Coding Expert (AMA); Medicare Claims Processing Manual, Chapter 12