Bill Dacey, MBA, MHA, CPC, CPC-I

I’m trying to come up with a statement I can use to document time I spend on hospital patients. Can I say, “I spent ___[X]____ minutes on the floor examining ___[Y]____, talking to the family, and placing orders”. Can I say, “MDM time,” which the ER physicians say in their notes?

 You are on the right track, but I’d suggest you say something a little different, now and in 2021 as well.

Although the definition of hospital time for coding purposes is described as 'floor time' that’s not really the part that needs to be spelled out. Like the 'counseling' time in the office, for inpatient time you need to document that over half of the total time was spent in either 'coordination of care' or ‘counseling’ and document what the total (floor) time was.

At minimum you need to say, “Spent over 1/2 of XX minutes coordinating care with A and B and C regarding X, Y and Z”. It's not a good practice to generically say, “coordinating with the rest of the team”, or “talking to the family, placing orders”. Instead, say “working with the social worker to arrange discharge” or “speaking with Mom and daughter about plans to do this or that ....”. That's the right way to do it. 

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Medicare, in particular, doesn’t care for generic time comments—these need to be personalized to the patient and the circumstances, and support medical necessity. 

And the “that's what the ER docs do” comment is a bit baffling—ER professional codes have never been able to be coded by time. No guidance ever suggested that the 'time' be linked to that spent on decision-making. That concept seems to be a mix of several guidelines that don’t take you there. Only during the pandemic were ER docs, like everyone else, allowed to code by MDM alone, and that was for telehealth visits only.

Remember that although the outpatient guidelines change in 2021 to eliminate the need for the ‘counseling or coordination of care’ aspects of coding by time, the inpatient codes are not impacted by this. The earliest that that could happen would be 2022, and that’s unlikely.

I have a question about medication reconciliation. Are there opportunities to bill for Med rec outside of the Transitional Care management codes 99495 and 99496?

A2: The TCM codes you mention seem to be the only fee-for-service CPT codes that specifically involve Medication reconciliation. And that is just one requirement of those codes. There is the quality measure code for 1111F for MIPS reporting that covers medication reconciliation performed within 30 days of a hospital discharge.

But when you ask about 'other opportunities' this may well have a place in the new definitions of time-based office visit codes 99202 – 99215 that will be fully in place come January 2021.

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In 2021, with the revised definition of time that includes some amount of pre- and post-visit activities, this could easily fit under the 'preparing to see the patient' or documenting clinical information in the EHR, with the Med recc time contributing to the overall time method of code selection.

Even now in 2020, were you to involve the patient in the process, this may in some circumstances count towards overall counseling time.

, MHA, MBA, CPC-I is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, documentation and compliance concerns for physicians. Bill is an evaluation and management (E/M) coding expert and has been active in physician training for more than 25 years. He can be reached at 

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This month’s Coding Q&A features questions from a physician coding for time spent with hospital patients, and another wondering if there is another way to code for medical reconciliation outside of Transitional Care management codes.

Coding Q&A: Coding for time spent with hospital patients; medication reconciliation

Bill Dacey, MBA, MHA, CPC, CPC-I, answers your latest coding questions in this Q&A session.

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Coding Q&A: Problem management credit with specialist involvement; A/P notes for AWVs

I’m an Internist and am wondering about the upcoming changes to the CPT Manual – specifically changes about ‘Problem Management’. Is it true that we will no longer get credit for assessing problems when a specialist is involved in their care? That hardly seems fair.

A1. No, that is not entirely true, but there have been some clarifications in the new EM guidance in CPT about which problems ‘count’ when determining the ‘Number and complexity of problems Addressed’ which is one of the components of determining Medical Decision-making (MDM).

The AMA published a section of the 2021 CPT Manual back in 2019 which provides definitions for the elements of (MDM) and some discussion of their use. There is a section about ‘problems addressed’ which attempts to clarify when you can and cannot include problems that are ‘managed by others’.

This is really a question about the extent of your involvement with a given issue, and what the guidance makes abundantly clear is that ‘A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service.’

It goes on to say that ‘Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being ‘addressed’ or managed by the physician or other qualified health care professional reporting the service.’ So, if we see Problem #4 in the Assessment and plan and it says – 4. CKD 3 – sees Nephrology…. This would clearly not be counted as problem that you have assessed that day.

However, if it said 4. CKD-3 – Continue monitoring GFR and Albumin and careful management of ACE and ARBs for HTN. See Nephrology next month – this clearly indicates the additional assessment of the CKD – in light of the patient’s HTN management- that would cause this to be included in the problem list. The practical issue here will be finding an easy way to say it. Even the ‘See nephrology’ might cover up more monitoring of this condition than we can see in the note.

A similar issue will come up with one of the other new definitions: ‘Referral without evaluation (by history, exam, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.’

This doesn’t mean that anything that is referred out can’t be counted, it just means you need to document your assessment or workup of that problem in order for it to be counted. We expect a good many more questions from this area.

I regularly bill for combination AWV’s and problem visits in the same encounter. My staff is telling me I’m not documenting to support both even though I include the problems addressed in the A/P section. What the heck else do I need?

Well, we can’t be sure what your staff thinks is missing, but if you have a decent A/P that includes clear problem management as well as the preventive and screening aspects of an Annual Wellness Visit (AWV) then the only thing that could be missing is on the front end of the note

The chances are that you use an EMR template to carry the AWV elements, pretty common since most of these are somewhat boilerplate and all AWV’s need to cover the same ground.

The templates typically dive right into the AWV – so probably you need to be certain that the problem portion has equal or significant presence at the beginning of the note. Make sure that you clearly state that the patient is ‘Here for their AWV and ongoing evaluation of X, Y and Z’. Name the problems to be addressed, and just like in any other chronic disease follow up visit – give a brief ‘status’ of them in the HPI. Give the problems some presence, so they don’t just ‘appear’ in the A/P.

Whenever you are billing for more than one cognitive or procedural service make sure the note says that you are doing two separate services. You are billing them for two—the -25 modifier means that there are two – make the dual nature of the visit very visible, from the outset.

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CPT Manual Changes: Will physicians still receive credit when a specialist is involved?

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Will physicians lose credit for assessing problems when a specialist is involved in their care? Also, documentation required to support AWV's and problem visits in the same encounter. 

Coding Q&A: Problem management credit with specialist involvement and A/P notes for AWV's

Some insurance companies have started not paying us for consults when they request notes and they don’t see the CC statement showing that the requesting provider received a copy of the note.

What if we create a part of the EMR that says

‘a copy of this note is stored in a shared chart with the referring provider therefore a hard copy is not being sent’. And do you know if they are going to keep paying for these in 2021?

 Yes, one of the requirements for consults is that ‘the findings are documented in the patient’s medical record and communicated by written report’, and a payer could deny if they can’t see this element. But don’t assume that an automated and generic one liner as you’ve indicated above will necessarily meet the requirement.

There are several things to consider: 1) If this becomes ‘part of the EMR’, then it could easily end up being used on new patient and other visits and quickly become ‘wallpaper’ and somewhat meaningless since it’s on everything, and 2)–This would only work for MDs in the same group or in the same EMR, and 3) It’s generic – and they like specific – ‘by written report to the requesting physician’ - not just ‘stored in the EMR’.

They’d much rather see some specific reference to an action taken – that the note was sent, faxed, tasked, shared etc. with Dr. X – that’s part of what the extra payment associated with these is for. The idea that there is an EMR ‘solution’ to every requirement is part of the reason the notes have become so bloated – lot’s of generic disclaimers and references intended to ‘cover’ a multitude of requirements. But they don’t really.

This one-liner also has the ‘referring’ provider language – which doesn’t always mean a consult as we know. The best advice is to get rid of referring language and actually require your providers to at least ‘fill in the blanks’ on something – ‘This consult report has been made available in the EMR to Dr. X in response to their consult request.’ And we don’t want to see it on new patients!

As to your second question – Are consults still going to be paid? – this is pretty clearly in the hands of the private payers. The AMA’s CPT manual has continued with these codes for over ten years after Medicare and most governmental payers stopped paying them, but it seems that every passing year another major payer either drops them or tries to limit payment for them. I wouldn’t bet on them long-term, the payer trend seems to be steadily away from them.

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Our coders have a disagreement about the use of the hospital admit codes.

CMS states that more than one provider may bill Initial Hospital Care as long as they are of a different specialty and the billing diagnosis is different. I was also able to find reference to this same guidance in the AAPC Procedure Desk Reference. However, the CPT Code book continues to state that only the admitting provider may bill for those Initial Hospital codes and all others must bill Subsequent Hospital Care Codes. So which one is right?

. Good question, it would seem that the AMA and CMA are saying opposite things – but they are both right in their own way. It's just that AMA /CPT doesn't take into account CMS's payment policy of using the 99221-99223 codes to cover the inpatient consults that they don’t pay for. So AMA’s guidance is a coding rule that applies to those ‘initial hospital care’ codes in their intended use as ‘admit’ codes. What CMS is showing you is essentially a payment policy that as above really accounts for different specialists using the ‘admit’ codes to represent their initial inpatient consults. Sometimes it hard to sort out coding rules versus more billing or payment-oriented guidance.

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Can you clarify the guidelines for coding 99213 vs 99214 on complexity vs time? After the COVID

waiver to expand video visit coverage I was advised that billing for video visits was based strictly on time. I have certainly had some Level 4 visits based on complexity of decision making but that last less than 25 minutes needed for Level 4 based on time.

 So whether it's a Telehealth visit with audio/video or a face-to-face office visit, at least for the duration of the PHE either vector allows you to code by total time 

 by the level of medical decision-making (MDM) alone.

As you may know this is also how the codes 99202 - 99215 will work starting in 2021 - time or MDM. That time being the MD time (attending time) and that time including some pre and post encounter elements not previously included (such as the time it takes you to type your note).

Back in March/April CMS had announced these upcoming 2021 rules would be in effect during the PHE. At this point, as 2021 draws near, we really don't see them going back to the 'old' way, although this is possible.

So in your scenario above, those visits that had (documented) moderate decision-making could have been billed as 99214's based entirely on that without regard to time. The EM office visits code have never been set up to have time as the key determinant of a code level. They had only allowed using coding by time as an option when certain circumstances led to the time becoming the predominant character of the visit, trumping as it were the level of MDM.

It is the online codes 99421 – 99423 and the audio only telephone codes 99441 - 99443 that must be coded based on the time involved. Maybe that's what you were thinking of.

Should providers should include notes in an EMR so insurance companies see CC statement? CMS vs CPT Code Book hospital admission coding. Plus, a clarification on guidelines when coding for telehealth visits. 

Author | Bill Dacey, MBA, MHA, CPC, CPC-I

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