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Cardiology Coding Alert

Billing E/M Using Time Can Boost Reimbursement

Published on Wed Aug 01, 2001

Cardiologists spend a lot of time with their patients reviewing test results and discussing treatment options, and many are missing reimbursement opportunities by not taking time into account when billing E/M services.
 
If they are not well informed about how time-based E/M coding works, cardiologists may bill visits using 99212 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: a problem focused history, a problem focused examination, or straightforward decision making), when they have really performed a 99213 (... expanded problem focused history, expanded problem focused examination, or medical decision making of low complexity) or 99214 (... detailed history, detailed examination, medical decision making of moderate complexity). Their notes may be in perfect order -- including documentation of the time spent with the patient -- but they continue to base E/M codes on history, examination and medical decision-making, even when the cardiologist performs only a minor examination but spends considerable time with the patient.
 
Physicians may bill for E/M on the basis of time. The introduction to the E/M section of CPT states:
 
When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (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. This includes time spent with parties who have assumed responsibility for the care of the patient or decision-making whether or not they are family members (e.g., foster parents, person acting in locum parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record.
 
 
In other words, if the cardiologist spends more than half the time of the visit going over test results and/or counseling or coordinating the care of the patient, the categories that normally determine levels of E/M services -- history, examination and medical decision-making -- are not taken into account (although they are still performed and should be documented).
 
Cardiology coders are cautioned not to bill E/M routinely using time. "This should not be used for just any office visit. It is not a typical method for choosing the level of service," says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. "Use time only for an exceptional visit -- for example, a visit that includes an extended discussion about things such as prognosis, test results or treatments." She notes that repeated billing of E/M with time as the main factor draws audit attention and limits the number of patients you can see.
 
There are also strict documentation guidelines when billing E/M based on time, including:
 
  • The time spent counseling or coordinating care must be more than 50 percent of the time spent with the patient
     
  • Time must be face-to-face with the patient (or whoever has assumed care of the patient)
     
  • Time counseling must be documented
     
  • The entire time of the visit is taken into account, not just time spent counseling or coordinating care.
    •  
    For example, a cardiologist sees a long-term patient with worsening cardiomyopathy to discuss treatment. The cardiologist indicates that a heart transplant may be needed. He or she then arranges to make the transplant available and refers the patient to a cardiac surgeon. The patient, however, has lots of questions and concerns, and the cardiologist wants to discuss the issues with the patient and his wife. The total time of the visit is 90 minutes. About 60 minutes of this was spent counseling the patient and his wife.
     
    In this situation, the cardiologist should report 99215 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: comprehensive history, comprehensive examination, medical decision making of high complexity), using the first 40 minutes spent as the factor that determines the level of E/M chosen, Callaway says.
     
    The remaining 50 minutes may be reported using 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]).
     
    Note: Prolonged services codes are time-dependent. They can only be used in conjunction with other E/M services that include a time component, such as office visits, inpatient visits and consults. They cannot be used on their own or with E/M codes that do not include a time component, such as ED services (99281-99285). Many carriers require that start and stop times be documented for prolonged service.
     
    The cardiologist may also spend time coordinating a patient's care during a visit. For example, a cardiologist sees a long-term cardiac patient who has no local family to help care for him. During the visit, the doctor and patient determine that the patient would be better off close to his family. The cardiologist uses the phone to try to place the patient in another city. While the phone arrangements are being made, the patient is present and interacting with the cardiologist, answering questions and so forth. The patient is present the entire time the physician is on the phone (30 minutes). The total visit was 40 minutes.
     
    The 40 minutes spent with the patient qualifies for a 99215 because coordination of care occurred for more than half the time, Callaway says. She adds that in both situations, the cardiologist must indicate the time and a summary of what transpired, such as: "Spent 35 minutes on phone with social worker trying to arrange adequate placement for patient with severe cardiac disease" or "Trying to contact physician who would be willing to assume care for the patient" or "Spent 90 minutes with patient and wife discussing treatment options. They were concerned about risks and benefits of each option, they will think about it and call back in a week. Patient was advised to continue on same meds in the meantime."
     
    Callaway also notes that only face-to-face time with the patient is counted toward the established office visit. Examination of test results away from the patient cannot be included. "Face-to-face time means just that," she says. "It doesn't mean time spent on the phone with the drugstore or the home-health company once the patient has left the office. The patient actually has to be in the office, not just waiting in the cardiologist's waiting room."
     
    Inpatient codes are the only exception to the face-to-face requirement. When cardiologists see inpatients, they may spend a lot of time not only counseling patients but also coordinating care with other caregivers, such as nurses, social workers and nursing homes. "For inpatients, you are allowed to use time spent on the unit and with nursing staff," Callaway says.
     
    For example, the cardiologist may discuss a patient's DNR (do not resuscitate) status with the patient's wife and children (i.e., counseling) or may talk to the patient about his treatment by the patient's bedside or coordinate the patient's care with a social worker on the hospital floor -- all of which qualifies for time-based E/M coding.
     
    Note: The level of some E/M codes cannot be determined on the basis of time. When coding for ED services or confirmatory consults, for example, the appropriate level has to be calculated using history, exam and decision-making only.

    Total Time of Visit Should Be Used
     
    It's easy to confuse the time spent counseling or coordinating care and the total time of the visit, says Laura Siniscalchi, RRA, CCS, CCS-P, a senior consultant in Deloitte & Touche's Boston office.
     
    "Say a visit that totaled 40 minutes included 25 minutes of counseling and 15 minutes history and exam. What matters is the total time, the 40 minutes," Siniscalchi says, noting that as more time is documented, the summary of what was discussed should correspondingly become more detailed. "The more details the summary has, the higher the level of E/M it will support," she adds.
     
    The cardiologist's notes should also indicate the total time spent with the patient and the amount of time spent counseling or coordinating care. In the example above, the cardiologist also spent 15 minutes taking the patient's history and performing an exam. The components of the history and exam (e.g., chief complaint, history of present illness) also need to be documented in the patient's chart. Otherwise, only the 25 minutes spent counseling will count, and the level of the visit would have to be reduced accordingly.

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