Expert Bill Dacey clarifies coding-for-time rules.
E&M coding gets an inordinate amount of attention. In large part this is due to the millions of times of these codes are reported each year and the billions of dollars in revenues or charges they represent.
In spite of this attention, and the fact that a large body of federal documentation guidelines has been devoted to these codes, there remain elements of their functionality that are either overlooked or simply escape the attention of many providers.
One of the biggest blind spots? Time.
The role of time
The codes in their current iteration were designed to be a more precise measurement of a physician’s cognitive work than the codes of any earlier era. Prior to 1992, the code descriptions read, in part, “brief,” “limited,” “extended,” “detailed,” and “comprehensive.” That first label, brief, surely referred directly to time - and so once many providers had the notion that these codes were meant to be coded based on time - some still do.
And it shouldn’t be news to providers today that most of the E&M codes still provide for coding by time in certain circumstances. It is likely that your office manager or coding staff has reminded you that when the majority of an outpatient visit is spent counseling the patient, that session is better coded by time than by the more conventional components of history, exam, and medical decision-making.
In fact, the E&M guidelines section of the CPT Manual clearly states that when counseling or care coordination dominates more than 50 percent of the encounter, then “time may be considered the key or controlling factor to qualify for a particular level of E&M service.” That means that when this type of activity occurs, time really is the better way to measure the provider work product since the component approach - history, exam, and medical decision-making - just doesn’t fit.
The CPT Manual has never really done a good job of making this clear. Each of the office and inpatient visit codes has the key components bolded, bulleted, and centrally placed in each code description. Below that are two paragraphs - the first stating that counseling or coordination care is performed as needed, the second detailing the severity of the presenting problem, then, finally, a statement, somewhat disembodied, that says the “physician typically spends XX amount of time with the patient and/or family.” There really isn’t anything that connects the first paragraph, which is about counseling and coordination of care, with the second part of the second paragraph, which directly references time.
This has caused confusion over the years. I still meet providers that think a 99213 is supposed to take 15 minutes, because the code description does contain that language - and it is not clear that the time factor is only meaningful when the encounter was dominated by counseling and coordination of care.
Again, to code by time, the encounter needs to be dominated by either counseling or coordination of care.
Outpatient visits coded by time mostly rely on the time spent counseling, since, in the office setting, the time spent must be face-to-face. (Although you do spend time on the phone discussing your patients’ care with other providers, or arranging for tests or procedures or placement, that work usually occurs after the patient leaves and does not qualify for coordination of care time because it wasn’t face-to-face.)
With some visits, you know in advance you’ll be doing mainly counseling. Others turn into counseling visits during the encounter.
Here’s an example of a visit that’s really all about counseling: A patient visits your office to discuss the results of some diagnostic tests taken at her annual health maintenance visit the week before. Perhaps the PAP results indicated a problem.
You discuss treatment options, risk, and agree on a course of action. The visit would be almost entirely characterized by discussion. Clearly this is one visit that is coded by time. You could make a case that there was some patient history involved, and surely some medical decision-making was part of if not the central portion of the visit - but the character of the visit was one of counseling, not the key components of history, exam, and decision-making.
Let’s say the entire discussion took 20 minutes. To support this in the chart, the documentation should simply state that, for example, “more than half of a 20-minute visit was spent discussing Sarah’s recent ASCUS PAP, her GYN history and current practices as regards HPV and monitoring/treatment.” This adequately supports a 99213. Simply mentioning the time of the total visit and the amount spent counseling may suffice, but I believe most payers would rather you provide some detail as to the nature of the discussion and the context of that counseling. You may also wish to avoid preprinted statements like the last one above. Payers are becoming more sensitive to “mechanized” portions of charts, templates, and electronic medical records - and this would include a convention that would appear to support coding by time but not actually stating your case.
There are also, of course, encounters that begin as normal episodic or chronic disease visits but take a turn toward the time-oriented visit. For example, a patient presents to the cardiologist to follow up on his previous heart attack. There is no current activity, and the patient is compliant with all direction and meds, but wants to talk more about how to further reduce cardiac risk by diet and exercise without further prescriptive agents. If the discussion went on long enough, this might change an encounter that was a 99213 by components into a 99214 by time.
Some presentations almost demand coding by time. Take the endocrinologist who sees a new diabetic patient for the first time. Although there will surely be a comprehensive history and comprehensive physical exam, the decision-making involved will likely be moderate to high complexity. But with those types of visits, it is almost a certainty that the endocrinologist will spend a great deal of time discussing the nature of the disease with the patient and essentially how that patient will need to live his life in order to deal effectively with diabetes. This takes time, and even for the patient who may have low-moderate level decision-making, the time factor will likely move these visits up into the 99205 range based on time - perhaps even beyond this into prolonged services.
In the course of reviewing and auditing thousands of inpatient records, I’ve noticed that physicians rarely code and document these visits by time. Just like the outpatient visit codes, hospital admission, follow-ups, and inpatient consult codes all have a provision to code by time.
There are two key differences between the way time is used in the inpatient setting. First, the inpatient codes represent a 24-hour period, one calendar day, not a visit like the outpatient codes. This is a huge difference when discussing time.
In a past life, I used to see the attending physicians in a teaching environment come back to their department offices after morning rounds about 10 am. They would deposit their small stack of charge tickets, inpatient census cards (or whatever their charge capture mechanism was), and tell their secretaries that “here are my charges for today.”
This was my cue to step out from behind the potted plant in the corner and remind the physicians that what they had done so far that constituted morning rounds only, and that they likely would be doing more work related to each of those, or at least some of those, patients later in the day. In fact, you can’t really assign an inpatient code, admit, follow-up or consult until the next day - when all the work is done.
The work associated with the inpatient visit codes includes not only that bedside initial or interval history, exam, and decision-making - either on the first or subsequent days - but also the work done on the patients’ floor, in the hallway, at the nursing station, and more.
The E&M section guidance in the CPT Manual defines time quite differently for the inpatient setting. “For reporting purposes,” it reads, “intra-service time for these services is defined as unit/floor time, which includes the time that the physician is present on the patient’s hospital unit and at the bedside rendering services for that patient. This includes the time in which the physician establishes and/or reviews the patient’s chart, examines the patient, writes notes and communicates with other professionals and the patient’s family.”
It continues: “In the hospital, pre- and post-time includes time spent off the patient’s floor performing such tasks as reviewing pathology and radiology findings in another part of the hospital.
“This pre- and post-visit time is not included in the time component described in these codes. However, the pre- and post-work performed during the time spent off the floor or unit was included in calculating the total work of typical services in the physician surveys.”
What provider doesn’t spend time above and beyond the bedside aspect of admissions or daily care - working on the chart, coordinating care with nurses, respiratory therapy, and other ancillary staff? How much time is spent reviewing the patient’s care with the family, with other providers that are consulting on the case?
When I had occasion to observe, I noticed that the charges many providers submit as daily charges are in fact charges associated with a single visit, usually morning rounds, even though there may well have been separate and significant coordination being performed throughout the day.
These inpatient codes represent the totality of work done, not just one aspect of it. Even on admissions, much of the work as far as history, exam, and decision-making may actually occur in the office prior to the actual admission, or in the ER.
When a provider goes to dictate the H&P that almost every facility demands be included in the chart within 48 hours or so, they will typically assign the code in relation to the breadth and complexity of that dictated H&P. But that may well not be all the work.
Once the patient gets to the floor, especially if this is a morning or daytime admission, there is the chart to set up, orders to write, other providers to be called, and various aspects of care to be arranged. Perhaps later in the day or the evening there is another face-to-face visit to assess treatment benefit or see if the plan of care is working out. All of this work adds up into the single code representing that day’s work.
If floor time spent exceeds 35 minutes in a day, and the total floor time spent is 70 minutes or more during the course of that day, then a 99222 - moderate complexity admit - becomes a 99223 admit based on time, if properly documented.
The times for subsequent inpatient care are 15, 25, and 35 minutes, respectively, for codes 99231, 99232 and 99233. Many providers rarely code a 99233 in the inpatient setting - citing that this requires the highest level of decision-making. And it does, unless you spent at least 18 of 35 minutes that day providing either counseling or coordination of care. That may seem a bit more common.
In any case, it’s high time providers recognized that these codes are more flexible than may at first appear and do have a mechanism to account for the value of a provider’s time. Take the time to learn the rules.
Bill Dacey is principal in The Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacy is a PMCC-certified instructor and has been active in physician training for over 10 years. He can be reached at email@example.com or via firstname.lastname@example.org.
This article originally appeared in the February 2006 issue of Physicians Practice.