E/M Level when time and MDM are documented

Q: A physician documents 20 minutes of time, which supports E/M code 99213; however, the medical decision making (MDM) involved supports a moderate level code (99214). Can we bill the higher-level code based on the MDM?It’s my understanding that the guidelines state to choose either total time on the date of the encounter or MDM.

A: Yes, it would be appropriate to report code 99214 if the MDM supports it. The code selection should be based on the most appropriate and relevant elements for a given patient encounter. The choice to select a code level based on time or MDM will vary depending on the presenting concerns of the patient, the time spent, and the complexity of the encounter. The CPT E/M guidelines for office or other outpatient visits do not designate the advantages of either MDM or time. Instead, the code-level selection and the determination to use either time or MDM should reflect the time and level of services provided for the patient’s presenting problem(s). Therefore, the code-level selection depends entirely on the nature of the visit.If the medical necessity of 99214 is supported by the MDM, it would be appropriate to bill the higher-level code.

Renee Dowling is a compliance auditor at Sansum Clinic, LLC, in Santa Barbara, California.