Answering your coding questions

What you need to know about prolonged services, medical assistant, and E/M codes.

Q:We are having difficulty billing prolonged services. There are two different codes, and how they are added is different. Can you give us some suggestions on how to manage this in our office?

A: Many coding concepts are fairly straightforward and can be left for the physicians to code. However, in my opinion, this isn’t one of those situations. Claims that include possible prolonged care should be reviewed by a coder. This is because there are different codes depending on payer, and the time thresholds are different. Current procedural terminology gives code 99417 and allows providers to add the 15 minutes to the lower time threshold in the range; the Centers for Medicare & Medicaid Services (CMS) offers G2212, which requires you to add the 15 minutes to the higher time threshold in the range.

You should keep in mind the following when billing prolonged services:

The evaluation and management (E/M) code needs to be selected based on time.

Prolonged codes can only be used with 99205 and 99215.

The total time must be documented, and the medical necessity needs to be supported in the note.

Currently, CMS does not require start and stop times.

There are specific elements that can and can’t be counted. I would suggest keeping a cheat sheet of these where you can easily reference it. Look for a description of what activities are included in the time because this is required when using time to select the office visit codes.

A good example of documenting time is, “I spent 90 minutes caring for the patient today, which included reviewing test results, documenting in the record and arranging for follow-up at pain management. It also included an extensive discussion with the patient and his wife regarding treatment options and recovery time, if he decides on surgery.”

Q:Can a medical assistant perform an annual wellness visit (AWV) if a physician or other qualified health professional is in the office suite during the visit?

A: Unless state regulations allow a medical assistant to conduct activities that require clinical judgment, the medical assistant would not be able to perform all the requirements of the AWV. Any portion of the AWV that requires clinical judgment (e.g., assessing cognition or discussing risks and benefits of treatment options for identified risk factors and conditions) must be performed by a person whose training and scope of practice include that level of clinical practice. However, a medical assistant can be part of the team of medical professionals providing the AWV services under the direct supervision of a physician, including helping the patient fill out the health risk assessment, if needed.

Q:When reporting my office E/M visits, can I include the time I spent reviewing and confirming my notes when I select the code for the visit?

A: You can only count the time you spend completing documentation on the date of the visit. If you review and sign off on your documentation at a later date, you cannot include that time to determine the level of service. For code selection, total time is the time on the date of the encounter that a physician or other qualified health care professional personally spends in activities related to the care of a single patient. This also applies to review of test results on a later date. Although it’s part of the work of the visit, the time spent reviewing test results is not included in the total time on the date of the encounter. Also remember that if you bill based on medical decision-making instead of time, the review of test results would be considered part of the order and not counted separately.

Because we are discussing the time spent on the date of visit, you also cannot include the time spent preparing for the visit (e.g., reviewing the patient’s previous visits, labs or other tests, consultant reports, etc.) on the day(s) prior to the visit.