# billing based on time - every office visit



## Colliemom (Sep 23, 2008)

What do you tell a physician who is submitting most of his/her office charges with the levels chosen based on time spent?  Shouldn't billing based on time be the exception rather than the rule?  This physician went from never billing/documenting time to now using time in every office visit.  How would you approach discussing this topic with your physician?


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## Belinda Frisch (Sep 23, 2008)

Here's a link to an article of Betsy Nicoletti's regarding this issue. 

I'd use the article to open conversation about why it's inappropriate to use time as the determining factor in CPT selection. 

Time should only be used when "counseling and coordination of care" dominates more than 50% of the visit and when the total time, time spent counseling, and content of counseling are documented. 

http://www.mpconsulting.org/resources/HCB Time.pdf

Good luck!




Katkia222 said:


> What do you tell a physician who is submitting most of his/her office charges with the levels chosen based on time spent? Shouldn't billing based on time be the exception rather than the rule? This physician went from never billing/documenting time to now using time in every office visit. How would you approach discussing this topic with your physician?


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## Colliemom (Sep 23, 2008)

Thank you!


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## okiesawyers (Sep 23, 2008)

Belinda Frisch said:


> Here's a link to an article of Betsy Nicoletti's regarding this issue.
> 
> I'd use the article to open conversation about why it's inappropriate to use time as the determining factor in CPT selection.
> 
> ...



Well said Belinda, Great article!


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## ARCPC9491 (Sep 23, 2008)

Katkia222 said:


> What do you tell a physician who is submitting most of his/her office charges with the levels chosen based on time spent?  Shouldn't billing based on time be the exception rather than the rule?  This physician went from never billing/documenting time to now using time in every office visit.  How would you approach discussing this topic with your physician?



To me, this is a coding issue and a practice management issue. To me, time should be an exception (others may disagree) - keep in mind, time is used when more than 50% of the encounter was spent counseling/coordinating care. Does your physician meet this criteria? It seems to me, correct me if i'm "assuming"  your physician is billing based on 'time' to be 'safe' - maybe they don't feel confident in E/M coding. I would explain to them, if you document, your levels of E/M might actually be higher than based on time .... 

Practice management - does your physician have productivity that he/she has to meet? If their coding based on time, how is their schedule layed out? are they quantifying on the number of patients they can see in one day? or is time a burden? 
i.e. Dr. A can 'document' 5 patients in one hour, whereas Dr. B coding based on time could see 3 patients in an hour, 20 minutes each.  In an 8 hour day, Dr. A has seen 40 patients and Dr. B has seen 24. In a normal office setting, if your seeing 20-22 patients a day, you're covering costs. Anything after, is profit. and this is important because if they are paid bonuses based on productivity, they'll listen! I could go on forever! LOL, but this is about CODING!  

Good luck!!


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## RebeccaWoodward* (Sep 23, 2008)

I'm curious...What is his/her specialty?  I do agree with Belinda's article.  Medical necessity is the key.  One of my groups is Reproductive Medicine.  The exams are minimal due to the nature of the specialty.  Counseling/time based billing are his key components.


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## Colliemom (Sep 23, 2008)

The physician in question is a gastroenterologist.  I audited his office charges.  Often, on examining his notes, I would see comments like "I spent a great deal of time counseling the patient in...." and "Lengthy discussion with patient on the natural progression of her disease."  I approached the physician to ask why he was not documenting the actual time spent in counseling these patients.  (He was concerned because he felt that his established patient visits should be billed at higher levels.)

So now the physician is documenting the time spent - adding comments like "At least 50% of this visit was spent on counseling and/or coordination of care. The total visit time was: 30 minutes."  However, now he is documenting MOST of his visits based on time and I was concerned.


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## RebeccaWoodward* (Sep 23, 2008)

I see your dilemma.  Again...this boils down to medical necessity and proper documentation.  I recently had an appt with my GI physician and this visit required extensive counseling.  In my head, I was doing my own audit for his services. Does anyone else do that?  Anyway...he did document and record the time accordingly.  I don't, _personally speaking_, think this should be a standard for all of your physicians visits, unless medical necessity and proper documentation is in place.  With Belinda's article and the CMS DG's, this should be an easy fix.


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## Colliemom (Dec 11, 2008)

I appreciate everyone's help with this question.  We are still trying to convince the physician that he should not be billing ALL of his office visits based on time.  

Does anyone have any links for other articles/documentation for why billing ALL office visits would be a bad idea?

Does anyone disagree, and think it is fine to bill all the office visits based on time, as long as the physician has supporting documentation of what was discussed during the counseling?


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## Lisa Bledsoe (Dec 11, 2008)

Keep in mind that the actual statement needs to state "greater than 50%...".  Stating "at least 50%" is not going to pass an audit.


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## LLovett (Dec 11, 2008)

I have a couple of physicians that bill almost exclusively on time.

Personally, I don't like it. One concern I have is being sure they can justify it in their schedules. If more time is billed than it appears was worked you have problems. I know of insurance companies that will have investigators sit and time patient in and out times at offices they suspect are billing for more time than is actually being spent with the patients. 

Another concern is medical necessity. You can only bill for what is medically necessary and that is harder to justify with time. I have to tell my providers repeatedly that just because the patient was difficult and took longer doesn't mean you get to bill a higher level based on time. The time has to be spent actually counseling and coordinating care not just repeating the same thing over and over because they have a difficult patient for whatever reason, or the patient got into a political discussion with them, etc...

I don't think there is anything wrong will billing based on time if it is justified and supported by all the documentation. It just seems to me there are a lot of ducks to keep in a row and most providers are better off not billing on time all of the time! 

Good luck,

Laura, CPC


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