# Documenting Time in E/M coding



## artdon2001 (Aug 15, 2008)

I have a provider who is a psychiatrist looking to code 99214 for his patients whom he sees for medication management.  He insists that he DOES NOT have to document the time spent.  I am in disagreement with him.  The 2008 CPT book states the 25 minutes is "typically" spent with the patient.  I called Medicare and they said YES - document the time time.  The 2008 CPT professional edition does not state that documentation guidelines have to state time spent.

Does anyone know where I can look to find in writing that E/M documentation guidelines specifcally states time must be documented?


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## dmaec (Aug 15, 2008)

How come he isn't using 90862 if that's all he's doing is med management?  
I'm not sure why he'd have to document time, it's nice to have - but if his documentation supports a level 4 it could be billed.  Time must be stated if you're billing by time.  The information for billing by time is in our CPT books.  In the E/M services guideline,  page 4 & 5 of the CPT 2008 professional edition. I don't see med management supporting a level 4, but then I haven't read the note! 
_{that's my opinion on the posted matter}_


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## artdon2001 (Aug 15, 2008)

*Documenting time for E/M service*

He was using 90862 in the past but determined he was undercoding based on the service he was performing, i.e., inquiring about medication reactions, efficacy, appearance, social interactions, etc.  Though there isn't counseling occuring, he is hitting the other elements; history, examination, MDM.  Based on his understanding of the documentation guidelines, he can be reimbursed at a higher rate if he simply documents everything he's been doing all along in his 90862 coding.

My other concern is that though he thinks he's hitting the constitutional findings, i.e. appearance; he's also responsible for documenting measurement of 3 of 7 vital signs.  He doesn't believe he has to document vitals.


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## dmaec (Aug 15, 2008)

show him the guidelines, it's in black & white - If he doesn't listen you'll have to go above him.  I'm sure the CEO won't want to be billing out charges that can't be supported.
_{that's my opinion on the posted matter}_


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## FTessaBartels (Aug 16, 2008)

*IF using time as determining factor for level of E/M*

*IF* the psychiatrist is using time as the determining factor to choose a level of service, *then *YES, time must be documented as follows:

Total time spent with patient face-to-face
Time spent face-to-face in counselling/coordination of care (must be >50% of total time)
What the nature of discussion was about.

*Example*: I spent 25 minutes with patient this date on counselling/coordination of care regarding medication managment. We discussed side effects, interactions, possible alternatives, expected outcomes. 100% of visit was in counselling/coordination of care. 

This would qualify for a 99214 without any exam, history or MDM.
Check CPT 2008 professional edition, the last page of the guidelines (pale green pages), last paragraph.  I'm at home and don't have my CPT book handy, but I think it's page 8. 

IF he's not meeting the bullet points for 99214, then the visit has to be coded at the level the documentation meets. 

F Tessa Bartels, CPC, CPC-E/M


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## artdon2001 (Aug 18, 2008)

*E/M documentation guidelines*

My provider isn't counting time.  He's stating that he has enough of the 3 elements to not have to document the time and that because he is not providing counseling or coordination of care, he doesn't have to document time.

Given this fact, he also doesn't feel that he need to perform 3 of the 7 required vital signs (BP, wt., ht., etc.) because he's already documenting the patient's general appearance.  My interpretation of the guidelines is that he has to document both.


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## Lisa Bledsoe (Aug 18, 2008)

artdon2001 said:


> I have a provider who is a psychiatrist looking to code 99214 for his patients whom he sees for medication management.  He insists that he DOES NOT have to document the time spent.  I am in disagreement with him.  The 2008 CPT book states the 25 minutes is "typically" spent with the patient.  I called Medicare and they said YES - document the time time.  The 2008 CPT professional edition does not state that documentation guidelines have to state time spent.
> 
> Does anyone know where I can look to find in writing that E/M documentation guidelines specifcally states time must be documented?



If he is coding based solely on time then YES he does have to document time (total time of visit/total time spent counseling/summary of counseling).  Otherwise, he must meet 2 of 3 key components for level of service, which in this case would most likely be the Hx and MDM......


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## FTessaBartels (Aug 22, 2008)

*2 of 3 for established patient*

If he is not using counseling / coordination of care, then he is correct - he does NOT need to document time. 

So, *if* his documentation has sufficient bullet points for 2 of the 3 key elements (most likely hx & MDM as Lisa pointed out), then he's right ... he can get a 99214

He needs two of the following three
*HISTORY:*
chief complaint
Expanded HPI (4+ elements)
Extended ROS (2-9 systems)
Pertinent PFSHx (at lesat 1 item of 1 PFSH area)

*EXAM:*
Detailed - "extended exam of affected body area or organ system AND other elated systems"

*MDM:*
Moderate complexity 

Instead of arguing with him, why not try to sit with him and figure out his optimum documentation to meet the requirements for 99214?  If you can go over a couple of his notes with an audit tool and show him where he doesn't meet the guidelines (or show yourself where he DOES), then you can arrive at a professional agreement on the correct code to bill.

F Tessa Bartels, CPC, CPC-E/M


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