Last week you examined a patient and took a history. After ruling out this or that, you began to suspect the worst. So you sent him off for the appropriate tests. The qualifications fit for a 99213, so that’s how you coded the visit.
Today, the results are back: cancer.
The patient returns and you relay the bad news. It’s a difficult visit. Lots of listening to someone whose body has let him down. You support your patient, impart critical information, reassure him that there’s hope, and discuss treatment options. Several members of the patient’s family are there, too, and they have questions. You spend 45 minutes on this counseling.
How on earth do you code that? You performed no physical exam. You took no additional history. You made no medical decisions. These are, of course, the base criteria for E&M coding; more or less activity in each category can bump the code up or down a notch. But what you did for this patient has real value — and it took more of your time than most visits. Lawyers charge by the hour. Why can’t you?
Or can you?
Yes, you can — sometimes. The key is to use time-based billing whenever possible. Essentially a separate path to the same E&M codes you normally use for office visits, time-based codes use time as the sole criterion for selecting a code. Using this method, you can actually bill the 45-minute appointment discussed above as a 99215.
Done right, time-based coding can make getting paid for the counseling aspect of practicing medicine much easier and more straightforward than standard E&M coding. In many cases, you’ll be able to use higher E&M codes without prompting an audit.
The caveat: Although it’s the easiest — and most lucrative — way to get paid for your time without converting your practice to a cash model (and we’ll get to that, too), time-based billing only works under certain circumstances. Here are the critically important provisos that must be satisfied:
- More than 50 percent of the time you’re with a patient must be spent on counseling or coordination of care. For example, let’s say you examine a wheezy patient and bring up the idea of quitting smoking. She is resistant, but after you take some time to show her some statistics on the Internet and also calculate her “smoker’s age” on some Web site, she comes around. So you move on to some serious discussion on smoking cessation, including medication options and lifestyle changes. The stethoscope to her chest took two minutes, while the discussion took 42 minutes. Use time-based coding.
- You cannot count time spent by ancillary service providers, such as a nurse drawing blood. Also, did you leave the room to go check on another patient? Sorry, that time doesn’t count toward this code.
- You must document the time, and what you discussed. This simply means notating in the chart how long you performed counseling and/or coordination of care for the patient.
- Your description of what you discussed must sound plausible for the amount of time you claim. Time-based coding in and of itself does not provoke an audit. Frankly, the payer only sees the billing code and the diagnosis code; it has no idea you coded based on time when your claim comes in. But it’s this combo you need to focus on to avoid raising a payer’s eyebrow. For example, coding to a level 4 using time-based rules with a diagnosis code for a plantar wart likely won’t cut it, even if the kid was incredibly uncooperative and wasted gobs of your time escaping from the exam room and squirreling his tiny body under a waiting room chair. Exasperating? Definitely. But it doesn’t qualify as a time-based code.
There are other ways to use time to code. You’ll want to consult an expert to get the nitty-gritty details, but here’s a brief rundown of some areas where you can code based on time:
- Prolonged services — Say you have a new patient whose medical history and current clinical issues are long and complex. Completing this initial exam seems to take much longer than usual. But here’s the good news: You can tack on a prolonged services code 99354 as a companion to the E&M code if the visit took 30 to 60 extra minutes to complete. More good news: You can add on a 99355 for every 30 minutes beyond that initial extra hour.
The CPT manual lists typical times that each code should take (see chart below), and the threshold times for tacking on the prolonged services codes.
- Modifier -22 — If you perform a procedure that normally would take a couple of hours, but, due to certain conditions — your patient is morbidly obese or has unexpected adhesions, for example — it ends up taking 12 hours, you don’t have to write off the extra 10 hours. You can attach Modifier -22 to the procedure code and get paid for the additional time you spent. Modifier -22 means that you performed services “significantly greater than usually required,” according to Medicare’s rules. Use it when warranted, but make sure you honor some important stipulations:
- It’s not enough to claim the procedure was difficult; you must explain why. For claims using Modifier -22, supply a written description that states exactly why the procedure was so hard and, therefore, took so long. A patient simply being obese won’t cut it; outlining how said obesity caused undue difficulty and, therefore, increased time will up your chances greatly.
- Include specific information to justify your claim. You must show a clear contrast between the normal time for a certain procedure vs. the actual time it took you.
- Include diagnoses and appropriate ICD-9-CM codes to back up your claims of added difficulty.
- Write the explanation so that a nonsurgeon can understand it. Use clear terminology and simple medical explanations. If the payer can’t comprehend what you’ve written, it is more likely to reject the modifier.
- Modifier -22 doesn’t work with all codes. You can only use Modifier -22 with procedure codes that have a global period of zero, 10, or 90 days. Everything else? Sorry, won’t work.
Tip: Even if you’ve never once had a case where you spent a great deal more time than normal on a certain procedure, always document the time anyway every time you do a procedure, says Barbara Cobuzzi, senior coder and auditor for The Coding Network in Beverly Hills, Calif., and president of practice management consulting firm CRN Healthcare Solutions. “Then when you have that exceptional case, and you bill that -22 modifier to get paid more money,” you can feel good about getting it because you have the historic documentation to show how this time was inordinately long, and you deserve to get paid more. - Patient discharge from hospital — Discharges from the hospital can be straightforward and, therefore, quite speedy, or they can be complex and, therefore, quite slow. If you don’t use a hospitalist, then acquaint yourself with time-based hospital discharge codes 99238 and 99239. Use the former when the discharge takes less than 30 minutes, the latter when it takes longer.
- Care plan oversight — Some of your patients have chronic conditions requiring your ongoing oversight, such as those receiving at-home IV treatment, slow-healing wounds, post-op patients, and the like. In these cases, you can bill based on time using care plan oversight codes. It’s a bit complex, but basically, every time you do anything that requires your attention to that patient’s treatment, document it. The threshold here is 30 minutes. “Once you reach that 30-minute mark, you’ve got the documentation to support the code,” says Marie Pelino, senior consultant and reimbursement specialist for practice management consulting firm SHR Associates in Annapolis, Md. “The time requirement is built in that you have to document you spent 30 minutes in the course of a day — accumulated time — on a treatment plan.”
If you have a number of patients like this, purchase a ledger book and when you go through all your chronic cases each day, you make note of everything you do. If a nurse is going out to a patient’s home, she calls in to report any changes. You may adjust the treatment plan then. Document this. “You must fill it out as you do it,” says Pelino.
