# Time based consultation question



## Tonyj (Aug 21, 2013)

Clinician sees a new pt for genetic counseling due to newly diagnosed breast ca. HPI is brief with no ROS and complete PFSH. No physical exam, MDM moderate. Time was given 60 mins with appropriate documentation. e.g. total time, content of discussion, more than half...

I don't believe this meets level due to the missing PE for a new pt. If time trumps E and M level do I need any of the above requirements i.e HPI, PE, MDM? I'm finding conflicting views on my web based search and my colleagues beg to differ.


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## Rhonda L Stewart (Aug 21, 2013)

*Rhonda L Stewart CPC, CCC*

The only way an Office E&M is billed based on time and this follows the CPT guidelines in your book. Face to Face time with patient and/or family/Caregiver is greater than 50% of the time is based on Counseling/Coordinating Care and Describing both in detail in the medical record.  I don't care if they say I spent 1 hour counseling and coordinating care, they need to document that "greater than 50 % of the hour was spent counseling/coordinating care and describe.  In the Hospital setting,  time is based spent at bedside or on the patients hospital floor or unit.  Look at Page 10 of your AMA CPT book under the heading Select the Appropriate Level of E/M Services Based on the Following.  Emergency Room is not counted in Time....  I hope this helps.


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## Tonyj (Aug 21, 2013)

Rhonda L Stewart said:


> The only way an Office E&M is billed based on time and this follows the CPT guidelines in your book. Face to Face time with patient and/or family/Caregiver is greater than 50% of the time is based on Counseling/Coordinating Care and Describing both in detail in the medical record.  I don't care if they say I spent 1 hour counseling and coordinating care, they need to document that "greater than 50 % of the hour was spent counseling/coordinating care and describe.  In the Hospital setting,  time is based spent at bedside or on the patients hospital floor or unit.  Look at Page 10 of your AMA CPT book under the heading Select the Appropriate Level of E/M Services Based on the Following.  Emergency Room is not counted in Time....  I hope this helps.



Documentation for time requirements was met. 

My question is pertaining to the elements i.e. no physical exam, no review of systems? Do I need at least a minimum in all 3 for new patients and 2 of 3 for established? i.e. HPI/PE/MDM I'm getting different opinions from co-workers as well as MCR!


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## tcoder5 (Aug 21, 2013)

You must have all three key components to bill for a consult.  Regarding time,  this is a gray area that I have difficulty with as well.  I believe you could bill for time if you had all 3 key components.


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## mhstrauss (Aug 21, 2013)

Tonyj said:


> Clinician sees a new pt for genetic counseling due to newly diagnosed breast ca. HPI is brief with no ROS and complete PFSH. No physical exam, MDM moderate. Time was given 60 mins with appropriate documentation. e.g. total time, content of discussion, more than half...
> 
> I don't believe this meets level due to the missing PE for a new pt. If time trumps E and M level do I need any of the above requirements i.e HPI, PE, MDM? I'm finding conflicting views on my web based search and my colleagues beg to differ.



I don't see any documentation in the CPT book that any of the 3 key elements (History, PE, MDM) are required to be performed when coding based on time, for any category of E/M services that allows time-based coding.  I've never come across this info from AMA, CMS, or my MAC.  As long as the provider documents appropriately for time-based coding, that is all that is needed.


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## tcoder5 (Aug 21, 2013)

Tony,

Check the link below out, it will be helpful.  

http://news.aapc.com/index.php/2010/02/go-beyond-the-basics-of-time-based-em-coding/

As CPT® evaluation and management (E/M) service guidelines explain, “When counseling and/or coordination of care dominates … the physician/patient and/or family encounter … time may be considered the key or controlling factor to qualify for a particular level of E/M services.” Specifically, in the office setting, time-based E/M coding requires that the physician spend half or more of the visit face-to-face with the patient and/or family providing counseling and/or coordination of care.

Use It, Don't Abuse It

Coding E/M services by time is simpler than reporting services according to history, exam, and medical decision making (MDM), but don't be tempted to report all E/M services by time. Keep in mind: the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services' (CMS) guidelines consider history, exam, and MDM to be the key components of E/M services, and allow coding by time only when 50 percent or more of The physician should include the components of history, exam, and MDM—even if cursory—in the documentation of every visit. Good medical record keeping requires documenting relevant and pertinent information. Using time as the controlling factor to qualify for a given E/M level does not negate this requirement.


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## FTessaBartels (Sep 11, 2013)

*Legitimate use of time-based coding*

This is a legitimate use of time-based coding. No PE is required.

Our pediatric general surgeons will sometimes see pregnant women in consultation regarding their unborn child and the surgery/treatment options the child will face once born. There is no PE ... it's all history, MDM and time-based counseling/coordination of care. 

Of course, the physician could always document something along the lines of:
*Patient is a well-nourished, pregnant female in no apparent distress.....*
That would be a PE (constitutional).  

But you really do not need it for these kinds of visits. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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