# Billing based on time



## MidwestCoder (Jul 15, 2013)

When time compenent is stated with the dictation 

TIME: 30 minutes with greather than 50% spent in direct face to face counseling and coordination of care.

For an established patient 30 minutes would be a 99214, but the dictation only meets a 99212 level. How does this work?

Thanks!


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## mitchellde (Jul 15, 2013)

As long as the documentation includes total time spent, and a concise counseling note then total time spent is the controlling factor, 30 minutes is  99214.  In addition the medical necessity must be documented for that much counseling.


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## MidwestCoder (Jul 15, 2013)

Thank you!


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## Monika Liddle (Jul 15, 2013)

*Billing Based on Time*

Review the "Select the Appropriate Level of E/M Services Based on the Following" E/M Guidelines section of your CPT Book. 

#3 When counseling and/or coordination of care dominates (more than 50%) the patient and/or family (face to face time in the office or other outpatient setting or floor/unit* TIME *in the hospital or nursing facility) then time may be considered the key or controlling factor to qualify for a particular level of E/M services.

An example of correct documentation: I spent 40 minutes with the patient and over 50% of the time was spent in counseling the patient on hypertension, diabetes and medication use.


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## MikeEnos (Jul 15, 2013)

Exactly, when counseling/coordination of care dominates (more than 50% of) the encounter, then *time *is the _controlling factor_ in code selection.  That means you select the level of service based on time - completely independent of the level of history, exam, and medical decision making complexity.  They do not have to all match up.

On the flip side - keep in mind that sometimes the knife cuts both ways.  You might have a note that seems to satisfy the requirements for a 99213.  However, if the documentation states that greater than 50% of this 10 minute encounter was spent counseling the patient regarding asthma, then it should be coded a 99212.  Time is supposed to be the controlling factor in code selection whenever greater than half of the time was spent in counseling/coordination of care.


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## MidwestCoder (Jul 15, 2013)

Would be okay to give an example of what I am seeing, so I can convey what I am struggling with. I am new to auditing and when time is involved I get a little confused.

A 51 year old female her for a follow-up. I intially saw her on 5/28 in consultation for both urinary frequency and urgency and hot flashes and cold sweats. She has an extensive history of urinary frequency and urgency and has had an extensive and appropriate urologic workup. I did start her on Ditropan XL 10 mg daily. We also discussed at that time possibly starting her on transdermal estrogen for her hot flashes bust decided to add only one thing at a time. She state that she is actually quite pleased with the improvement she has seen with teh Ditropan. She sstates that her urinary frequency and urgency has improved approximatley 65%.  This improvement is mostly during the day. She still does get up several times at night due to urinary urgency. She also reports that her hot flashes have improved at least 90% and are to the point where they are manageable. I am not quite sure the etiology of this but she is very pleased.

O: Afebrile. Vital signs stable. General:  Alert, oriented x 3 and in no acute distess.

A/P:
1. 51 year old with overactive bladder symptoms, currently using Ditropan XL 10 mg daily. Again, she has expereinece an improvement in her symptoms which she rates at 65%. The nocturia is still problematic for her. Overall, she is pleased. At this point we are going to go another 4 weeks to see if she can gain any more improvement.
2. Menopausal symptoms. She has improved on the antivholinergic medication prescribed for her overactive bladder. At this time, she does not feel she needs estrogen. If this does become problematic she would be a canidadte for low-dose transdermal estrogen.

Time 15 minutes with greater than 50% spent in direct face to face counseling and coordinatio of care.


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## MikeEnos (Jul 16, 2013)

Yes, that's a 99213 with a good time statement.  It is evident in the A/P what the content of the discussion was.  If they were to list it more clearly, that would be great, but this documentation is sufficient.


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## LLovett (Jul 16, 2013)

*Refernce please*

Hi Mike, can you please provide a reference that supports time must be used if documented as you stated above. 

I have never heard this and my book uses the word "may" not must.

Thanks

Laura, CPC, CPMA, CEMC


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## MikeEnos (Jul 16, 2013)

That's open for interpretation, I have nothing other than the CMS Evaluation and Guidelines which states:



> There are three key components when selecting the appropriate level of E/M service
> provided: history, examination, and medical decision making. Visits that consist
> predominately of counseling and/or coordination of care are an exception to this rule.
> _*For these visits, time is the key or controlling factor to qualify for a particular level of
> E/M services.*_


(emphasis mine)

That seems to me to indicate that whenever counseling dominates the encounter, then time is the controlling factor in code selection, it supersedes the history, exam, and MDM whether it increases or decreases the level.  Some feel that it should only be used when it is advantageous (similar to the use of the 95 or 97 guidelines) and I can't necessarily say you're wrong if you feel that way, but I have a different interpretation.


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